RIVERSIDE  TEXTBOOKS 
IN  EDUCATION 

EDITED  BY  ELLWOOD  P.  CUBBERLEY 

PROFESSOR    OF   EDUCATION 
LELAND   STANFORD  JUNIOR   UNIVERSITY 


THE  HYGIENE  OF  THE 
SCHOOL  CHILD 


BY 

LEWIS  M.  TERMAN 

ASSOCIATE   PROFESSOR  OF   EDUCATION 
LKLAND  STANFORD  JUNIOR  UNIVERSITY 


HOUGHTON  MIFFLIN  COMPANY 
BOSTON    NEW  YORK    CHICAGO    SAN  FRANCISCO 

presp  Cambridge 


COPYRIGHT,    1914,   BY   LEWIS  M.  TERMAN 
ALL  RIGHTS   RESERVED 


ITfe  fcibtrsfof  fines 

CAMBRIDGE  .  MASSACHUSBTTS 
PRINTED  IN  THE  U.  S.  A. 


TO 
WILLIAM  H.  BURNHAM 


2052868 


EDITOR'S  INTRODUCTION 

THE  editor  of  this  series  has  long  held  that  an  effi- 
cient teacher  should  know  something  as  to  the  fun- 
damental principles  of  child  hygiene,  and  that  a 
school  principal  should,  in  addition,  know  the  fun- 
damentals of  schoolhouse  hygiene.  For  schoolhouse 
hygiene  we  have,  for  some  time,  had  a  number  of 
fairly  serviceable  texts,  but  of  books  relating  to  child 
development  and  the  hygiene  of  instruction  we  have 
had  but  little  in  any  form  that  teachers  could  use. 
Only  recently  may  we  be  said  to  have  come  into  the 
possession  of  such  knowledge,  and  most  of  it  is  still 
locked  up  in  medical  and  psychological  journals  and 
books. 

The  following  treatise  on  the  "Hygiene  of  the  School 
Child"  is  an  attempt  to  digest  and  interpret  this 
recently  accumulated  knowledge,  and  to  place  it  in 
usable  form.  The  book  might  have  been  called,  with 
almost  equal  propriety,  a  treatise  on  the  "  Hygiene  of 
Growth,"  dealing,  as  it  does,  so  largely  with  the  funda- 
mental facts  of  a  child's  physical  development.  In  a 
companion  volume,  to  be  published  later,  the  author 
will  continue  his  interpretations  by  setting  forth  the 
relation  of  mental  hygiene  to  the  work  of  the  school. 
In  the  two  volumes,  then,  "The  Hygiene  of  the  School 
Child,"  and  "The  Hygiene  of  Instruction,"  will  be 


viii  EDITOR'S  INTRODUCTION 

presented  the  fundamental  facts  of  child  hygiene  and 
development,  such  as  parents,  teachers,  and  students 
of  education  should  know. 

The  time  when  the  preparation  of  teachers  can  be 
made  by  a  study  of  psychology  and  methods  ought  to 
pass.  When  it  does  it  will  mean  that  the  health  and 
physical  welfare  of  a  child  will  then  be  regarded  as  of 
as  much  importance  as  arithmetic  and  geography,  and 
then  a  knowledge  of  the  elements  of  child  hygiene  will 
be  regarded  as  of  fundamental  importance  in  the 
training  of  every  teacher.  In  many  colleges  and  nor- 
mal schools  such  a  change  is  now  taking  place,  and  it 
is  for  such  use  that  this  textbook  has  been  prepared. 
Teachers  in  service,  too,  ought  to  find  such  informa- 
tion as  is  contained  in  the  following  pages  of  great 
interest  to  them  personally,  and  of  much  usefulness  to 
them  in  their  relations  with  their  children. 

Such  an  interpretation  of  scientific  researches  relat- 
ing to  growing  children  as  this  book  contains  ought 
also  to  prove  of  much  interest  and  value  to  that  large 
and  rapidly  increasing  number  of  parents  who  are 
interested  in  the  proper  rearing  and  education  of  their 
children. 

ELLWOOD  P.  CUBBERLET. 


PREFACE 

THIS  work  has  been  prepared  as  a  textbook  in  school 
hygiene  for  the  use  of  normal  schools,  colleges,  and 
teachers'  reading  circles.  It  has  been  shaped  by  the 
conviction  that  the  primary  concern  of  such  a  text 
should  be  the  child  itself,  —  the  hygiene  of  physical 
and  mental  growth,  rather  than  the  details  of  school 
architecture  and  school  equipment.  The  architect  and 
the  engineer  working  alone  cannot  guarantee  the 
healthfumess  of  school  life.  Hygienic  buildings  and 
equipment  are  necessary,  but  they  do  not  go  far  in  the 
conservation  of  the  child.  Moreover,  the  average 
teacher  has  little  voice  in  the  construction,  ventilation, 
lighting,  and  equipment  of  school  buildings.  She  must 
accept  these  as  she  finds  them.  But  she  has  hourly 
opportunity,  in  her  control  of  school  activities,  to 
observe  or  to  violate  the  principles  relating  to  the 
hygiene  of  physical  and  mental  development. 

On  the  phases  of  school  hygiene  here  treated  there 
exists,  in  spite  of  many  regrettable  gaps,  a  large  and 
valuable  literature.  Most  of  it,  unfortunately,  has 
remained  hidden  away  in  medical  treatises  and  scien- 
tific periodicals  on  hygiene.  The  author  has  endeav- 
ored to  summarize  and  interpret  the  best  of  this 
rather  technical  literature  for  the  use  of  teachers  and 
parents. 


x  PREFACE 

If  European  investigations,  particularly  those  of 
German  writers,  are  quoted  more  often  than  American 
sources,  this  is  because  school  hygiene  as  a  science  has 
been  little  cultivated  in  our  own  country.  America 
does  not  yet  have  a  single  periodical  of  school  hygiene; 
Germany  has  at  least  four  of  excellent  scientific 
quality. 

It  would  be  vain  to  expect  that  a  work  having  the 
scope  of  the  present  volume  could  be  kept  free  from 
error.  Either  for  lack  of  positive  investigations,  or 
because  of  conflicting  data,  many  of  the  subjects 
treated  remain  in  dispute.  In  such  cases,  it  is  not 
always  easy  to  be  judicial  and  impartial. 

The  author  is  indebted  largely  to  the  counsel  and 
encouragement  of  friends  for  whatever  merit  this  work 
possesses.  Dr.  E.  B.  Hoag,  Specialist  in  Child  Hygiene 
for  the  Minnesota  State  Board  of  Health,  has  fur- 
nished helpful  suggestions  for  chapters  xn  to  xv, 
inclusive.  Dr.  E.  B.  Huey,  Assistant  in  Psychiatry, 
Johns  Hopkins  University,  has  given  invaluable 
assistance  hi  the  preparation  of  the  chapters  on  "Pre- 
ventive Mental  Hygiene."  Without  the  inspiration  of 
Professor  William  H.  Burnham,  the  work  would  not 
have  been  undertaken;  without  the  encouragement 
of  the  editor  of  the  series,  it  could  not  have  been 
completed. 


CONTENTS 


CHAPTER  I 

INTRODUCTION:  THE  BROADER  RELATIONS  OF  EDUCA- 
TIONAL HYGIENE 

School  hygiene  as  a  part  of  the  problem  of  conservation. 
The  cost  of  preventable  disease.  The  relation  of  education  to 
the  conservation  of  life.  Health  work  in  the  schools  must 
be  extended.  References. 


CHAPTER  H 

THE  PHYSICAL  BASIS  OF  EDUCATION 13 

The  biological  perspective.  Importance  for  education  of 
such  problems  as  those  relating  to  growth,  morbidity,  rela- 
tion between  mental  and  physical  conditions,  etc.  Neglect 
of  physical  education.  References. 

CHAPTER  III 

THE  GENERAL  LAWS  OF  GROWTH 20 

Sources  of  data.  Tables  and  curves  of  growth.  Absolute 
increment  and  percentile  increment  in  growth.  Oscillations 
in  growth.  Growth  rate  and  resistance  to  disease.  Relation- 
ship between  physical  and  mental  growth.  Relation  of 
pubertal  retardation  to  ultimate  size.  References. 
t 

CHAPTER  IV 

THE  FACTORS  INFLUENCING  GROWTH 82 

The  internal  factors:  racial  heredity  and  immediate  ances- 
try. The  external  factors:  poverty,  nutrition,  housing,  sea- 
sonal influence,  effects  of  school  life,  alcohol,  drugs,  etc. 
References. 


xii  CONTENTS 

CHAPTER  V 

SOME  PHYSIOLOGICAL  DIFFERENCES  BETWEEN  CHIL- 
DREN AND  ADULTS       47 

General  differences.  Circulatory  system.  Digestive  sys- 
tem. The  respiratory  system.  The  muscular  system.  The 
skeletal  system.  The  nervous  system.  The  lack  of  regularity 
in  growth.  References. 

CHAPTER  VI 

THE  EDUCATIONAL  SIGNIFICANCE  OF  "PHYSIOLOGICAL 
AGE" 61 

Distinction  between  chronological,  anatomical,  and 
physiological  age.  Anatomical  age.  Physiological  age.  Con- 
clusions. References. 

CHAPTER  VH 

DISORDERS  OF  GROWTH  AND  THE  HYGIENE  OF  POSTURE    72 

Spinal  curvature.  Review  of  investigations  showing  fre- 
quency. Kyphosis  (outward  curvature).  Exercises  for  cor- 
rection of  kyphosis.  Lordosis  (inward  curvature).  Scoliosis 
(lateral  curvature).  Injuries  produced  by  spinal  curvature. 
Causes  of  spinal  curvature:  rickets,  tuberculosis  of  bone,  un- 
even length  of  legs,  postural  causes,  etc.  Table  summarizing 
chief  defects  and  their  causes.  References. 


CHAPTER 

MALNUTRITION  IN  SCHOOL  CHILDREN 98 

The  importance  of  nutrition.  Are  many  children  ill- 
nourished  ?  Inadequate  feeding  as  a  cause  of  malnutrition. 
Other  causes.  Identifying  the  ill-nourished.  The  responsi- 
bility of  the  school.  School  feeding.  Children's  dietaries. 
References. 

CHAPTER  IX 

TUBERCULOSIS  AND  THE  SCHOOL 127 

The  ravages  of  tuberculosis.  Tuberculosis  in  childhood. 
Review  of  investigation  of  incidence,  sources  of  infection. 


CONTENTS  mi 

etc.  Means  of  prevention.  What  the  school  can  accomplish: 
instruction  in  personal  hygiene,  a  hygienic  program,  play- 
grounds, school  baths,  seating,  open-air  schools,  school 
medical  and  dental  clinics,  etc.  References. 


CHAPTER  X 

THE  PHYSIOLOGY  OF  VENTILATION  .......  148 

Ventilation  not  merely  a  problem  of  engineering.  The 
physiology  of  respiration.  The  part  of  the  lungs,  blood, 
heart,  and  muscles  in  the  respiratory  process.  The  mechan- 
ism of  respiration.  Source  of  injury  produced  by  bad  air. 
The  chemical  theory.  Theory  of  organic  poisons.  Influ- 
ence of  air  currents,  temperature,  and  humidity.  The  body's 
heat-regulating  mechanism.  Healthy  vasomotor  action. 

CHAPTER  XI 

THE  TEETH  OF  SCHOOL  CHILDREN  .......  167 

The  problem.  What  examinations  of  children's  teeth  have 
disclosed.  Injuries  produced  by  defective  teeth:  mastica- 
tion, general  poisoning,  nervousness,  mental  alertness, 
growth,  etc.  Causes  of  dental  caries.  Prevention.  Teaching 
of  mouth  hygiene.  Orthodontia.  Indications  of  dental 
defects.  References. 

CHAPTER  XH 

THE  HYGIENE  OF  THE  NOSE  AND  THROAT   .    .    .    .197 

Relation  of  nose  and  throat  to  health.  Enlarged  tonsils. 
Adenoids.  Effects  of  adenoids.  Causes  of  adenoids.  Sug- 
gestions for  observation.  Summary.  References. 


CHAPTER 

DEFECTS  OF  HEARING  AND  THE  HYGIENE  OF  THE  EAR  221 

The  prevalence  of  defective  hearing.  The  importance  of 
hearing  for  mental  development.  Discharging  ears.  The 
causes  of  defective  hearing.  The  responsibility  of  the  school. 
Directions  for  testing  hearing.  Special  schools  for  deaf  chil- 
dren. Some  indications  of  ear  defects.  References. 


xiv  CONTENTS 

CHAPTER  XIV 

THE  HYGIENE  OF  VISION 245 

New  demands  on  the  eye.  The  mechanism  of  vision. 
Definition  and  discussion  of  eye  conditions.  Emmetropia. 
Hyperopia.  Myopia.  Astigmatism.  Muscular  deviations. 
Eye-strain  in  relation  to  visual  defects.  Signs  and  symptoms 
of  eye-strain.  Directions  for  testing  vision.  Summary  and 
conclusions.  School  lighting,  school  work,  school  oculists, 
etc.  References. 

CHAPTER  XV 

THE  HEADACHES  OF  SCHOOL  CHILDREN 282 

Frequency.  Causes.  Prevention.  References. 

CHAPTER  XVI 

PREVENTIVE  MENTAL  HYGIENE 289 

I.  THE  NERVOUS  CHILD. 

Some  nervous  disorders  are  functional.    Symptoms  of 
,  nervous  disorders:   physical,  emotional,  volitional,  moral, 
etc.    Suggestions  for  observation. 

CHAPTER  XVH 

PREVENTIVE  MENTAL  HYGIENE 299 

II.  COMMON  NEUROSES  OF  DEVELOPMENT. 

Psychasthenia.  Hysteria.  Dementia  prsecox.  Chorea. 
Tics,  habit-spasms,  etc.  Epileptic  school  children. 

CHAPTER  XVm 

PREVENTIVE  MENTAL  HYGIENE 318 

III.  THE  EDUCATION  OP  NERVOUS  CHILDREN. 
Faulty  education  as  related  to  nervous  disorders.    The 

value  of  social  experience.  Methods  of  discipline.  Training 
in  self-reliance  and  self-control.  Cultivating  habits  of 
efficiency.  The  sanifying  effects  of  work.  Danger  of  shock. 
Special  schools  for  nervous  children.  Selected  references. 


CONTENTS  xv 

CHAPTER  XIX 

SPEECH  DEFECTS  AND  THE  HYGIENE  OF  THE  VOICE  335 

Stuttering  as  a  handicap.  The  incidence  of  speech  defects. 
Lisping.  Stuttering.  Causes  of  stuttering.  The  treatment 
of  stuttering  children  in  special  schools.  Method  used.  The 
prevention  of  speech  defects.  Suggestions  for  observing 
speech  defects.  References. 

CHAPTER  XX 

THE  SLEEP  OF  SCHOOL  CHILDREN 862 

The  amount  of  sleep  needed.  Theoretical  norms.  Investi- 
gations of  children's  sleep :  Bernhard,  Ravenhill,  Terman  and 
Hocking.  The  relation  of  sleep  to  intelligence,  school  success, 
"nervous  traits,"  etc.  Sleep  of  the  feeble-minded.  Explana- 
tions for  lack  of  correlation  between  hours  of  sleep  and  men- 
tal efficiency.  The  conditions  of  children's  sleep.  External 
conditions.  Internal  conditions.  Teaching  children  to  sleep. 
Suggestions  for  a  sleep  survey  of  school  children.  References. 

CHAPTER  XXI 

SOME  EVIL  EFFECTS  OF  SCHOOL  LIFE 381 

The  problem.  The  school  as  a  cause  of  morbidity.  The 
effects  of  school  life  upon  growth.  Effects  upon  appetite, 
nutrition,  and  the  composition  of  the  blood.  The  formal 
examination.  Effects  of  school  postures  upon  respiration. 
Psychopathological  effects  of  school  life.  The  annual  accu- 
mulation of  fatigue.  Types  of  children  likely  to  be  injured 
by  the  work  and  environment  of  the  school.  References. 

SUGGESTIONS  FOR  A  TEACHER'S  PRIVATE  LIBRARY  ON 
THE  HYGIENE  OF  PHYSICAL  AND  MENTAL  GROWTH  408 

GLOSSARY 410 

INDEX  .....  .  413 


LIST  OF  ILLUSTRATIONS 

Facing 

Dr.  Rotch's  radiographs  of  the  hands  of  children  .  ^  .       .     62,  63 
Round  shoulders,   lateral    curvature,   and   "wing"   shoulder 

blades  in  forward  shoulders  • 76 

A  very  serviceable  test  for  posture  94 

The  phenomena  of  dental  caries  and  the  development  of  an 

abscess 176 

The  replacing  of  the  temporary  teeth 1' 

The  results  of  orthodontia 

The  primary  incision  for  separating  the  hypertrophied  tonsil 

from  its  attachments 212 

Before  and  after  the  removal  of  adenoids 213 


LIST   OF  FIGURES  AND  CHARTS 

1.  Growth  in  height  and  weight               23 

2.  Annual  percentile  increment  of  growth  in  weight  and  height  24 

3.  How  the  proportions  of  a  new-born  child  differ  from  those 

of  the  adult .V    .      .       .47 

4.  Increase  in  lung  capacity 52 

5.  Increase  in  strength  of  grip  for  right  hand 54 

6.  Percentage  of  each  pubescence  sub-group  for  each  half-year 
group 64 

7.  A  "C"  curve  resulting  from  uneven  extremities     ...  80 

8.  One-sided  position  from  standing  on  one  foot        ...  81 

9.  The  correct  position  for  recitation  or  prolonged  standing  .  81 

10.  Desk  too  high 82 

11.  The  progress  of  an  "S"  curve  under  treatment  for  three 
years 85 

12.  Flat-foot 87 

13.  One  of  the  first  signs  of  flat-foot          88 

14.  Imprint  of  (1)  arched  foot,  and  (2)  flat-foot    ....  89 

15.  A  passage  blocked  by  adenoids 208 

16.  A  clear  passage  to  the  lungs 209 

17.  Emmetropic  or  normal  eye 247 

18.  Hypermetropic  or  long-sighted  eye 248 

19.  Diagram  to  illustrate  accommodation 248 

20.  Myopic  or  short-sighted  eye 249 

21.  Curve  of  fatigue  for  eye  accommodation 266 


LIST  OF  FIGURES  AND  CHARTS          xvii 

22.  Percentage  of  children  lisping  or  stuttering  in  the  first  six 
grades 339 

23.  Line  indicating  the  monotony  of  the  stutterer's  voice  .       .  356 

24.  Line  indicating  how  the  normal  voice  should  rise  and  fall  .  356 

25.  Amount  of  sleep  children  actually  receive  compared  to 
Duke's  theoretical  standard 867 

26.  Extremes  hi  amount  of  sleep  secured  at  different  ages  .       .  368 

27.  Sleep  of  mentally  defective  children  compared  with  that  of 
normals 372 

28.  Increase  of  morbidity  with  age  among  1900  girls  in  German 
middle  schools 383 

29.  Increase  of  morbidity  with  age  among  500  girls  in  a  German 
secondary  school 384 

30.  Percentage  of  certain  defects  according  to  grade  for  pupils 

in  the  secondary  schools  of  Russia 386 

81.  Effect  of  school  entrance  on  the  size  of  children's  spontane- 
ously controlled  drawings 399 

32.  Annual  curve  of  fatigue  in  school  children       ....  401 
88.  Curve  of  mental  fatigue  during  the  school  year   .      .      .  402 


THE  HYGIENE  OF  THE 
SCHOOL  CHILD 

CHAPTER  I 

INTRODUCTION:  THE  BROADER  RELATIONS  OP 
EDUCATIONAL  HYGIENE 

School  hygiene  as  a  part  of  the  problem  of  conservation 

THE  rapid  development  of  health  work  in  the  schools 
during  the  last  two  decades  is  not  to  be  regarded  merely 
as  an  educational  reform,  but  rather  as  the  corol- 
lary of  a  widespread  realization  of  the  importance  of 
preventivejneasures  in  the  conservation  of  natural  and 
human  resources.  The  prevention  of  waste  has  be- 
come, in  fact,  the  dominant  issue  of  our  entire  political, 
industrial,  and  educational  situation. 

In  many  ways  society  is  enlarging  its  interest  in  the 
individual.  The  laissez-faire  policy  of  a  few  genera- 
tions ago  is  being  replaced  by  humanitarian  foresight, 
restrictive  measures,  and  large  cooperative  social  un- 
dertakings. We  are  rapidly  becoming  conscious  of  hith- 
erto unsuspected  power  to  shape  human  destinies 
and  are  no  longer  willing  to  remain  the  passive  play- 
thing of  uncontrolled  social  and  material  forces.  The 
evolution  concept  is  doing  its  work.  Having  at  last 
consented  to  look  at  ourselves  from  the  biological  point 
of  view,  we  proceed  to  harness  the  biological  and  social 
forces  which  will  make  for  the  development  of  a  hap- 


2      THE  HYGIENE  OF  THE  SCHOOL  CHILD 

pier,  healthier,  and  better  race.  Evolution  has  made  us 
conscious  of  a  future,  has  shown  us  how  to  attain  it, 
and  most  important  of  all,  has  made  that  future  a 
matter  for  our  practical  concern.   Our  highest  boast  is 
\  coming  to  be  that  we,  the  present  generation,  are  living 
i  not  only  for  ourselves,  but  also  for  the  generations  that 
1  are  to  follow. 

Of  course  it  must  be  admitted  that  Utopias  for  the 
betterment  of  human  conditions  are  not  a  new  inven- 
tion. The  imagination,  fortunately,  has  always  found 
satisfaction  in  the  fanciful  creation  of  an  ideal  social 
structure.  But  previous  to  recent  governmental  and 
scientific  advances  such  dreams  were  but  empty  fan- 
cies, incapable  of  realization.  The  forces  which  make 
or  mar  the  destinies  of  man  were  far  less  amenable  to 
control  than  is  the  case  to-day.  At  present  the  develop- 
ment of  industrial  processes  and  the  various  sciences  of 
conservation  give  us  hope  that  at  least  the  worst  con- 
tditions  of  poverty  can  be  done  away  with;  the  remarkT 
able  progress  of  medicine  demonstrates  that  many  of 
man's  physical  ills  can  be  overcome  and  many  others 
eliminated  by  preventive  means;  and  finally,  the  laws 
•>  ,.  of  heredity,  when  fully  known  and  heeded,  are  capable 
of  raising  the  average  of  mental,  moral,  and  physical 
endowment  well  above  where  it  now  stands.  Every 
civilized  nation  is  becoming  acutely  conscious  of  the 
necessity  of  utilizing  all  possible  means  for  conserving 
these  vital  resources  and  of  adding  to  them. 

Among  the  greatest  of  these  influences  is  medicine, 
preventive  and  curative.   Such  diseases  as  smallpox, 


INTRODUCTION  8 

tuberculosis,  diphtheria,  malaria,  yellow  fever,  typhoid, 
bubonic  plague,  and  cerebro-spinal  meningitis  have 
rapidly  yielded  up  secrets  which  make  it  possible,  for 
the  most  part,  either  to  prevent  the  disease  or  to 
cure  it.  The  technique  of  diagnosis  and  of  surgery  has 
been  refined  beyond  the  boldest  prophecy  of  a  few 
decades  ago.  With  the  growth  of  our  understanding  of 
disease  there  goes  pari  passu  a  keener  sensitiveness  to 
the  presence  of  physical  imperfections.  We  now  know 
that  an  amazing  amount  of  physical  defectiveness  has 
always  stared  us  in  the  face  without  our  recognition. 
Among  the  masses  of  people,  however,  there  remains 
a  vast  amount  of  ignorance  with  regard  to  matters  of 
health  and  disease.  The  daring  researches  of  a  few 
score  bacteriologists  are  more  than  offset  by  the 
thousands  of  people  who  still  use  liverwort  for  jaundice 
because  of  the  fancied  resemblance  of  its  leaf  to  the 
human  liver;  by  the  tens  of  thousands  who  treat  infec- 
tious diseases  by  suggestion;  by  the  millions  who 
spend  hard-earned  money  for  patented  consumption- 
cures.  Popular  notions  regarding  personal  hygiene  are 
little  better  than  a  seething  welter  of  ignorance  and 
superstition,  not  all  of  which  is  confined  to  those  who 
are  confessedly  uneducated. 

The  cost  of  preventable  disease 

The  cost  of  this  ignorance  in  money,  sickness,  death, 
and  grief  is  stupendous.  Basing  his  estimate  upon  sta- 
tistics of  mortality  for  ninety  different  diseases  and 
accepting  the  expert  opinion  of  numerous  medical 


4      THE  HYGIENE  OF  THE  SCHOOL  CHILD 

specialists  as  to  the  ratio  of  preventability  for  these 
diseases,  Professor  Irving  Fisher  has  reckoned  that  the 
general  adoption  of  a  few  well-established  hygienic 
principles  would  add  fifteen  years  to  the  average  span 
of  human  life.  For  the  most  part  these  fifteen  lost  years 
would  be  years  of  economic  productivity.  It  is  evident 
that  every  premature  death  entails  an  economic  loss 
upon  society,  varying  according  to  the  age  of  the  per- 
son dying.  It  is  computed  that  the  newborn  child  has 
an  average  money  value  of  at.  least  $95.  The  value 
increases  to  $960  by  five  years,  to  $4000  by  twenty 
years,  and  drops  again  to  $2900  by  fifty  years.  The 
minimum  average  loss  to  society  from  each  postpon- 
able  death  has  been  elaborately  figured  at  $1700.  Of 
the  1,500,000  deaths  in  the  United  States  each  year  the 
combined  opinion  of  the  best  medical  authorities  re- 
gards at  least  42  per  cent  to  be  postponable,  or  600,000. 
The  annual  loss  to  the  country  from  this  cause  is  there- 
fore $1700  X  600,000,  or  $1,070,000,000. 

Nor  does  this  complete  the  story  of  waste.  For  each 
unnecessary  death  there  are  several  cases  of  unneces- 
sary illness,  the  total  cost  of  which,  counting  medical 
attendance  and  wages  lost,  amounts  to  nearly  $1,000,- 
000,000  more.  The  Great  White  Plague  alone  involves 
an  annual  loss  of  not  less  than  $500,000,000.  Typhoid 
fever  costs  us  some  $200,000,000;  malaria,  $100,000,- 
000,  besides  its  indirect  injury  in  undermining  health; 
and  the  hookworm  disease  an  equal  amount.  It  is  esti- 
mated that  there  are  from  2,000,000  to  3,000,000  cases 
of  malaria  in  the  United  States  each  year,  and  that 


INTRODUCTION  5 

about  2,000,000  persons  suffer  from  the  hookworm 
disease.  The  loss  of  economic  efficiency  from  alcohol- 
ism, vicious  habits,  undue  fatigue,  minor  ailments,  and 
lack  of  expert  direction  of  the  human  machine  can  only 
be  vaguely  guessed  at,  but  it  is  probably  greater  than 
that  from  all  the  other  causes  enumerated.  Apart  from 
this,  however,  we  suffer  an  aggregate  calculable  loss 
from  preventable  illness  and  death  of  about  $2,000,- 
000,000  per  year,  or  over  four  times  the  total  ex- 
penditures for  public  education.  This  is  equal,  at  4  per 
cent,  to  the  annual  interest  on  $50,000,000,000. 

The  meaning  of  such  figures  can  be  made  more  clear 
by  a  comparison  with  other  values.  The  total  physical 
wealth  of  the  United  States  has  been  estimated  at 
about  $110,000,000,000,  and  the  value  of  our  annual 
agricultural  products  at  about  $9,000,000,000.  Our 
railways  are  worth  about  $17,000,000,000,  and  the 
annual  output  of  our  manufactures  about  $15,000,000,- 
000.  Our  vital  assets,  however,  are  by  far  the  most 
important  of  all.  Adopting  Professor  Irving  Fisher's 
figure  of  $2900  as  the  average  value  of  one  individual 
to  society,  the  total  economic  value  of  our  90,000,000 
inhabitants  reaches  the  sum  of  $250,000,000,000.  This 
is  almost  exactly  1000  times  the  value  of  our  hogs,  for 
the  conservation  of  which  the  nation  expends  more 
money  than  it  does  for  the  conservation  of  its  children. 

But  statements  of  economic  loss  do  not  fully  repre- 
sent the  importance  of  health  conservation.  Waste  of 
life  or  health  involves  grief  and  moral  suffering  which 
cannot  be  measured  in  gold.  Infant  mortality  illus- 


6      THE  HYGIENE  OF  THE  SCHOOL  CHILD 

trates  the  point.  In  the  most  enlightened  countries 
from  15  to  20  per  cent  of  the  infants  die  in  the  first  year 
of  life.  In  Russia,  Austria,  southern  Italy,  and  even  in 
limited  districts  of  England  and  Massachusetts  infant 
mortality  reaches  30  to  40  per  cent.  Although  the 
economic  significance  of  infant  mortality  is  much  less 
than  that  of  tuberculosis,  morally  the  two  problems 
are  of  nearly  equal  importance. 

The  relation  of  education  to  the  conservation  of  life 

In  the  work  of  conserving  national  vitality  we  can- 
not rely  altogether  upon  the  progress  of  medical  science 
and  upon  reforms  of  public  health  administration. 
These  measures  must  be  supplemented  by  a  never- 
ending  campaign  for  the  enlightenment  of  the  young 
in  matters  of  personal  and  social  hygiene.  The  practice 
of  hygiene  in  the  average  home  follows  far  in  the  rear  of 
medical  discoveries. 

Infant  mortality  again  offers  an  apt  illustration. 
Bacteriology  teaches  that  from  one  half  to  two  thirds 
of  infant  deaths  are  due  to  the  neglect  of  a  few  simple, 
hygienic  precautions.  In  spite  of  this  fact,  statistics 
demonstrate  that  this  needless  slaughter  has  been  but 
little  affected  by  the  advances  of  preventive  medicine. 
It  will  continue  little  abated  unless  the  new  generation 
is  educated  to  a  different  hygienic  viewpoint.  In  the 
prevention  of  infant  mortality,  as  well  as  in  the  con- 
servation of  vitality  in  general,  no  other  agency  is 
capable  of  contributing  as  much  as  the  public  school. 

Numerous  conditions  peculiar  to  modern  life  have 


INTRODUCTION  7 

forcibly  called  our  attention  to  the  problems  of  hygiene. 
Among  these  are  the  industrial  changes  of  the  last 
century  and  the  consequent  urbanization  of  the  poptt 
lation.  In  1790,  but  3.4  per  cent  of  the  population 
dwelt  in  cities  of  8000  or  over.  By  1900,  this  had  risen 
to  33.1  per  cent.  The  growth  of  cities  has  greatly  com- 
plicated the  problems  relating  to  food,  housing,  con- 
tagious disease,  etc.  Industrial  methods  have  multi- 
plied dangerous  employments,  have  specialized  in  a 
most  unhealthful  way  the  physical  activities  involved 
in  work,  and  have  often  favored  the  most  wearisome 
and  monotonous  occupation  of  the  mind. 

So  radical  are  the  adjustments  which  civilization 
demands  in  our  habits  of  living  that  the  factors  which 
controlled  and  directed  the  evolution  of  the  human 
body  have  in  large  part  become  inoperative.  Our 
modes  of  sedentary  life  tend  less  and  less  to  bring  into 
play  the  physical  traits  which  were  of  greatest  value  in 
the  primitive  struggle  for  existence.  Instead,  excessive 
burdens  are  laid  upon  functions  and  organs  never 
intended  by  nature  to  endure  them. 

If  only  the  intentions  of  nature  were  respected  during 
the  period  of  growth  and  development  the  problem 
would  by  no  means  be  so  serious.  The  youth  who  has 
been  brought  into  possession  of  his  full  psycho-physical 
inheritance  would  be  in  a  position  to  conserve  this 
inheritance  in  the  face  of  great  odds.  This  we  do  not  , 
permit.  The  healthful  play  of  children  has  ever  become 
more  difficult.  The  introduction  of  universal  educa- 
tion has  changed  the  whole  life  of  the  child  from  one 


8       THE  HYGIENE  OF  THE  SCHOOL  CHILD 

of  active  to  one  of  sedentary  occupation.  As  stated  by 
Gulick,  "so  extensive  a  readjustment  of  the  life  habits 
of  the  young  of  a  species  has  never  before  been  at- 
tempted." 

We  do  not  yet  know  what  the  result  of  this  experi- 
ment will  be,  but  it  is  unreasonable  to  suppose  that 
man  presents  any  exception  to  the  biological  law  that 
the  ultimate  survival  of  an  organism  is  threatened 
whenever  it  is  subjected  to  conditions  of  environment 
widely  different  from  those  which  directed  its  evolu- 
tion. We  have  taken  the  child  out  of  its  natural  habi- 
tat of  open  air,  freedom,  and  sunshine,  and  for  nearly 
hah*  his  waking  hours  we  are  subjecting  him  to  an 
unnatural  regimen,  one  which  disturbs  all  the  vital 
functions  of  secretion,  excretion,  digestion,  circulation, 
respiration,  and  nutrition. 

If  all  children  were  perfectly  healthy  when  received 
into  the  school,  they  might  be  expected  to  make  the 
adjustment  with  little  or  no  permanent  injury.  But 
the  school  does  not  deal  chiefly  with  healthy  children. 
Medical  inspection  in  scores  of  American  cities  demon- 
strates that  as  a  rule  not  more  than  one  third  of  our 
school  children  are  free  from  physical  defects  preju- 
dicial to  health.  Of  the  20,000,000  children  enrolled  in 
our  schools  some  14,000,000  are  more  or  less  handi- 
capped in  this  way. 

Not  far  from  2,000,000  (10  per  cent)  are  suffering 
from  a  grave  form  of  malnutrition;  10,000,000  (50  per 
cent)  have  enough  defective  teeth  to  interfere  seriously 
with  health;  at  least  2,000,000  (10  per  cent)  suffer  from 


INTRODUCTION  9 

obstructed  breathing  due  to  adenoids  or  enlarged  ton- 
sils; probably  2,000,000  (10  per  cent)  have  enlarged 
cervical  glands  which  need  attention,  many  of  these 
being  tuberculous;  at  least  10,000,000  (50  per  cent)  are, 
or  have  been,  infected  with  tuberculosis,  of  whom 
about  2,000,000  (10  per  cent)  will  later  succumb  to  the 
disease;  4,000,000  (20  per  cent)  have  defective  vision; 
over  1,000,000  (5  per  cent)  have  defective  hearing; 
about  1,000,000  (5  per  cent)  have  spinal  curvature  or 
some  other  deformity  likely  to  interfere  with  health; 
not  far  from  500,000  (2|  per  cent)  have  organic  heart 
disease;  and  at  least  1,000,000  (5  per  cent)  are  predis- 
posed to  some  form  of  serious  nervous  disorder. 

Health  work  in  the  schools  must  be  extended 

The  fact  that  the  school  doctor  has  been  called  in 
to  examine  and  advise  does  not  signify  that  the  gravity 
of  the  situation  has  been  apprehended.  Teachers  have 
simply  found  physical  defects  an  impediment  to  the 
pupil's  school  progress  and  desire  their  removal.  The 
school  doctor  spends  some  three  to  six  minutes  in  the 
examination  of  each  pupil,  looking  only  for  the  gross 
and  external  symptoms  of  defectiveness.  Having  usu- 
ally the  point  of  view  of  the  physician,  his  search  is  for 
disease.  His  training  has  not  always  fitted  him  to  dis- 
cover incipient  deviations  from  the  normal  or  even  to 
see  the  necessity  of  doing  so. 

Our  plea  is  for  a  broader  conception  of  the  functions 
and  scope  of  educational  hygiene.  The  usual  attention 
given  to  heating,  lighting,  ventilation,  and  gross  physi- 


10     THE  HYGIENE  OF  THE  SCHOOL  CHILD 

cal  effectiveness  is  but  the  merest  beginning.  The 
school  instead  of  causing  sickness  and  deformity  must 
be  made  to  preserve  the  child  from  all  kinds  of  mor- 
bidity, repair  his  existent  deformities,  combat  his 
unfavorable  heredity  and  the  bad  conditions  of  his 
environment;  in  a  word,  fortify  his  constitution  and 
render  him  physically  and  mentally  fit  for  the  struggles 
of  life. 

The  greatest  problem  of  conservation  relates  not  to 
forests  or  mines,  but  to  national  vitality,  and  to  con- 
serve the  latter  we  must  begin  by  conserving  the  child. 
We  are  hampered,  however,  by  the  lack  of  positive 
knowledge  of  the  influences  which  mold  a  child's  physi- 
cal and  mental  development.  Many  of  the  questions 
relating  to  this  problem  can  never  be  answered  until 
they  have  been  attacked  on  a  broad  scale  by  system- 
atic and  scientific  methods  of  research.  To  secure 
proper  scope  for  such  research,  the  schools  must  be 
thrown  open  to  it;  to  insure  adequate  support,  it  must 
be  made  a  public  undertaking.1 

No  other  agency  compares  with  the  school  in  the 
opportunities  offered  for  contributing  to  the  health  of 
the  succeeding  generation.  We  cannot  legislate  desir- 
able habits  of  living  into  men  and  women,  but  we  may 
be  able  to  mold  after  our  ideals  the  hygienic  habits  of 
the  child. 

The  most  characteristic  tendency  of  present-day 
education  is  its  progressive  socialization,  the  increas- 

1  For  a  list  of  unsolved  problems  in  child  hygiene  see  reference  2% 
at  end  of  this  chapter. 


INTRODUCTION  11 

ing  extent  to  which  society  is  utilizing  the  school  as  an 
instrument  for  the  accomplishment  of  its  ends.  We  are 
coming  to  believe  that  it  is  legitimate  to  levy  upon  the 
school  for  any  contribution  it  is  capable  of  making  to 
human  welfare.  This  social  conception  of  education  is 
quite  familiar.  Only  let  us  extend  its  application  to  all 
fields  of  personal  and  social  hygiene  and  the  school  will 
help  to  deliver  us  from  a  burden  which  is  more  oppres- 
sive than  the  burden  of  militarism;  for  physical  ineffi- 
ciency, sickness,  and  premature  deaths  are  costing  us 
as  much  as  all  our  crime  and  as  much  as  a  good-sized 
perpetual  war  besides. 

Apart  from  such  considerations  as  the  above  it  is  not 
possible  to  understand  or  evaluate  the  modern  crusade 
for  medical  and  hygienic  supervision  of  schools.  It 
began  as  a  reflection  of  the  popular  interest  in  matters 
of  health;  it  will  end  by  becoming  the  most  effective 
and  convenient  instrument  for  the  attainment  of  a 
higher  national  vitality. 

REFERENCES 

(References  of  greatest  value  for  the  chapter  in  question  are  marked 
with  a  star.) 

*1.  W.  H.  Allen:  "A  Broader  Motive  for  School  Hygiene."  Atlan- 
tic Monthly,  June,  1908. 

*2.  W.  H.  Burnham:  "The  Problems  of  Child  Hygiene."    Fed. 

Sem.,  1912,  pp.  395-402. 

3.  Dr.  Myrtelle  Canavan:  "Medical  Data  from  the  Examination 
of  2333  Supposedly  Normal  Women."  Proc.  6th  Cong.  Am. 
Sch.  Hyg.  Assoc.,  1912,  pp.  76-91. 

*4.  Elsa  Denison:  Helping  School  Children.  1912,  pp.  352. 

*5.  Norman  Ditinan:  Education  and  Preventive  Medicine.    1911, 
pp  73. 


12     THE  HYGIENE  OF  THE  SCHOOL  CHILD 

*6.  Sigmund  Engel:   The  Elements  of  Child  Protection.    London, 

1912,  pp.  276.  Translated  by  Eden  Paul. 
*7.  Irving  Fisher:  "Report  on  National  Vitality."   1909,  pp.  138. 

Bull.  No.  SO  of  Com.  of  100  on  National  Health. 
*8.  Sir  John  E.  Gorst:  The  Children  of  the  Nation.  1906,  pp.  297. 
9.  Hastings  W.  Hart,  et  al:  Preventive   Treatment  of  Neglected 

Children.   1910,  pp.  419. 

*10.  Heller,  Schiller   u.  Taube:    Enzyklopadisches   Handbuch   des, 
Kinderschutzes  u.  der  Jugendfiirsorge.  Bande  i-n.  Leipzig,  1911. 
*11.  Dr.  A.  H.  Hogarth:  The  Medical  Inspection  of  Schools.   1909, 
pp.  360.   (Chapters  v  to  vm.) 

12.  Arthur  Holmes:  The  Conservation  of  the  Child.  1912,  pp.  345. 

13.  Dr.  Woods  Hutchinson:  Preventable  Diseases.  1909,  pp.  442. 
*14.  J.  Johnson:  Wastage  of  Child  Life.  1909,  pp.  381. 

15.  G.  B.  Mangold:  Child  Problems.    1910,  pp.  381.    (Especially 
pp.  1-158.) 

16.  Earl  Mayo:  "The  Problem  of  National  Health."   The  Outlook. 
December  7,  1912,  pp.  464-172. 

*17.  Benjamin  Moore:  The  Dawn  of  the  Health  Age.  Liverpool. 
1910,  pp.  204. 

•18.  George  Newman:  Infant  Mortality.   1907,  pp.  356. 
19.  Dr.  Max  Schlapp:  "  Our  Perilous  Waste  of  Vitality."  The  Out- 
look, April  6,  1912. 

*20.  John  Spargo:  The  Bitter  Cry  of  the  Children.  1906,  pp.  336. 

21.  Harold  Spender:  "A  National  Health  Charter."  Contemporary 
Review,  June,  1911. 

22.  Lewis  M.  Terman:  "Professional  Training  for  Child  Hygiene." 
Pop.  Sci.  Mo.,  1912,  pp.  289-97. 

23.  J.  M.  Tyler:  Growth  and  Education.  1907,  pp.  297.  (Chapter  I.) 

24.  J.  E.  W.  Wallin:  "Aspects  of  Infant  and  Child  Orthogenics." 
The  Psych.  Clinic,  1912,  pp.  153-72. 

25.  T.  D.  Wood:  "Health  and  Education."    Ninth  Year  Book, 
National  Soc.  for  Study  of  Education,  1910,  pp.  113. 

26.  Proc.  of  Conference  on  the  Conservation  of  School  Children. 
Published  by  the  American  Academy  of  Medicine.   1912,  pp. 
293. 

*27.  The  Public  Health  Movement.    Published  by  the  Am.  Acad.  of 

Polit.  and  Soc.  Sci.,  1911,  pp.  298. 
•28.  Vol.  Ill  of  Proc.  of  the  Fifteenth  International  Cong,  in  Hyg. 

and  Demog.,  1913,  pp.  486. 


CHAPTER  II 

THE  PHYSICAL  BASIS  OF  EDUCATION 

The  biological  perspective 

IT  is  necessary  for  us  as  teachers  to  take  the  biological 
point  of  view  in  all  our  thinking  and  to  seek  our  edu- 
cational philosophy  in  the  laws  of  growth.  The  task  of 
molding  human  lives  is  one  which  can  be  accomplished 
only  by  an  appeal  to  those  biological  processes  which 
are  common  alike  to  animals  and  to  man.  For  in  the 
strictest  sense  man  is  as  much  a  natural  product  of 
evolutionary  laws  as  are  his  brothers  of  the  forest.  His 
biological  equipment  is  in  general  the  same;  the  num- 
ber and  distribution  of  his  parts,  the  individual  tissues 
even,  and  to  no  small  extent  the  physiological  function- 
ing of  all  his  organs.  He  is  subject  to  many  of  the  same 
diseases  and  is  tormented  by  the  same  parasites.  Be- 
cause man's  nervous  system  is  built  upon  the  same 
general  plan  as  that  of  the  other  higher  mammals,  his 
mental  equipment  differs  from  theirs  more  in  degree 
than  in  kind.  His  senses  are  the  same,  he  is  moved  by 
similar  instincts  and  emotions,  and  his  intellect  em- 
braces no  "faculty  "  which  is  not  present  in  cruder  form 
in  the  mental  life  of  other  animals.  He  is  obedient  to 
the  same  laws  of  heredity,  and  is  therefore  capable  on 
the  one  hand  of  improvement  by  eugenics,  and  on  the 
other  hand  subject  to  racial  degeneration. 


14    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

For  the  understanding  of  childhood,  especially,  the 
biological  perspective  is  absolutely  essential.  It  is  then 
that  natural  instincts,  primitive  modes  of  mentation, 
and  growth  influences  of  remote  origin  are  most  in  evi- 
dence. If  the  lengthened  period  of  immaturity  in  man 
is  not  conceived  of  in  its  evolutionary  setting,  education 
cannot  set  a  rational  goal  or  choose  aright  the  processes 
by  which  the  goal  is  to  be  attained.  It  is  our  tendency 
to  view  the  child  as  a  being  set  apart  from  the  rest  of 
organic  creation  which  causes  us  to  neglect  the  physi- 
cal limits  and  determinants  of  human  possibilities,  to 
teach  children  as  though  they  were  disembodied  spirits, 
to  judge  the  child  by  adult  standards,  to  forget  that 
the  best  of  education  is  but  wisely  directed  growth. 
Besides  a  general  biological  orientation,  such  as  might 
be  expected  from  a  well-planned  course  dealing  with 
man's  place  in  nature,  every  teacher  should  have  con- 
siderable acquaintance  with  the  problems  and  princi- 
ples mentioned  hi  the  following  paragraphs. 

(a)  The  order  of  physiological  maturity.  Every  part 
of  the  body  has  its  own  order  of  development  and 
its  own  critical  periods,  the  nervous,  muscular,  circu- 
latory, respiratory,  and  digestive  systems  in  particu- 
lar. Education  must  follow  this  order,  measuring  its 
demands  and  requirements  by  the  child's  stage  of 
maturity.  Many  an  educational  problem  is  solved  by 
growth  alone. 

(6)  The  main  factors  in  mortality  and  morbidity.  The 
teacher  should  know  what  diseases  are  prevalent  among 
children  at  various  stages  of  development.  The  degree 


THE  PHYSICAL  BASIS  OF  EDUCATION      IS 

of  resistance  to  disease  determines  in  large  measure  the 
kind  of  education  the  child  should  have.  Instruction 
can  wait,  as  Dr.  Burnham  reminds  us,  but  the  demands 
of  health  are  imperative.  Health  first,  then  education, 
should  be  the  motto.  We  have  hardly  begun  to  appre- 
ciate the  real  significance  of  a  clean  bill  of  health  and 
heredity.  We  make  no  inquiries  of  this  sort  regarding 
the  new  pupil,  but  ask  only  his  marks  in  the  subjects  of 
instruction.  It  is  necessary  to  know  something  about 
all  the  physical  abnormalities  commonly  met  with 
among  school  children,  defects  of  eyes,  ears,  nose  and 
throat,  teeth,  spinal  deformity,  malnutrition,  anaemia, 
nervous  states,  etc.  This  knowledge  should  include  for 
each  defect  something  of  its  causes,  its  effects  upon 
general  health,  its  symptoms,  and  the  appropriate 
methods  of  treatment,  both  educational  and  medical. 
Too  often  tuberculosis  steals  the  child  or  spinal  curva- 
ture deforms  him  while  we  wrangle  over  rival  methods 
of  teaching  him  geography  or  grammar  or  spelling. 

(c)  The  relation  between  mental  and  physical  condi- 
tions. The  nervous  system  is  so  ultimately  concerned 
in  every  act  of  knowing,  feeling,  ajid  willing  that,  if  our 
knowledge  were  only  greater,  education  could  be  de- 
scribed in  purely  neurological  terms.  When  we  know 
more  about  the  physical  basis  of  mental  life  we  shall 
quit  teaching  grammar  to  feeble-minded  children  who 
cannot  learn  to  count  money.  We  shall  appreciate  the 
wisdom  of  the  old  proverb  which  tells  us  that  "it  is 
impossible  to  make  a  silk  purse  out  of  a  sow's  ear." 
We  shall  understand  that  the  difference  of  some  bil- 


16    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

lions  of  brain  cells  between  the  imbecile  and  the  genius 
is  a  difference  which  education  cannot  wipe  out  or 
afford  to  ignore.  We  shall  not  expect  to  find  normal 
instincts,  emotions,  intelligence,  or  conduct  in  children 
who  are  unhealthy  or  disinclined  to  play.  We  shall 
understand  that  fatigue  and  work  have  their  strict 
physiological  determinants  dependent  upon  bodily 
rhythms,  the  disintegration  of  cell  tissue,  the  accumu- 
lation of  toxins,  processes  of  waste  elimination,  repair, 
and  the  like.  We  shall  think  even  of  criminality,  tru- 
ancy, inattention,  laziness,  etc.,  in  terms  of  a  possible 
physical  cause. 

(d)  The  dynamic  aspects  of  education.  The  education 
of  the  mind  is  closely  related  to  the  activity  of  the 
muscles.  In  the  race  and  in  the  individual,  mind  and 
muscle  develop  together.  The  human  hand  and  the 
human  intellect  would  each  have  been  impossible  with- 
out the  other.  The  low-grade  feeble-minded  are  always 
deficient  in  motor  power  and  in  delicacy  of  coordina- 
tions. Their  cerebral  activities  are  as  clumsy  as  their 
manual,  and  the  former  can  be  improved  by  the 
education  of  the  latter.  The  motor  element  is  present 
hi  all  our  thinking.  Every  school  subject  has  its  dy- 
namic aspect.  We  cannot  truly  possess  knowledge  until 
we  have  used  it.  A  thing  is  what  we  can  use  it  for;  our 
idea  of  it  is  determined  by  our  motor  attitude  toward 
it. (One's  whole  personality  is  a  bundle  of  accomplish- 
ments and  possible  accomplishments^)  Thinking,  bio- 
logically speaking,  is  never  its  own  end,  but  a  means 
V}ward  adaptation,  which  is  essentially  motor. 


THE  PHYSICAL  BASIS  OF  EDUCATION      1? 

When  we  have  applied  this  biological  point  of  view 
in  our  educational  psychology  we  shall  less  often  exalt 
knowing  above  doing.  Much  of  the  time  we  now  give 
to  book  instruction  will  be  replaced  by  opportunities 
for  activity.  The  educational  aim  will  lose  its  bifur- 
cated aspect  and  the  child  will  be  recognized  as  an 
organic  unity.  The  child's  mind  will  cease  to  be  the 
enemy  of  his  body,  and  the  welfare  of  each  will  be 
sought  in  the  maximum  culture  of  the  other. 

Knowledge  without  health  cannot  profit  us.  "Non 
scolse,  sed  vitse,"  interpreted  by  hygiene,  means  that 
success  in  life  depends  as  much  on  the  integrity  of  the 
energy-getting  processes  as  on  the  accumulation  of 
knowledge,  and  that  the  school  dare  not  confine  its 
work  to  the  latter.  Emerson  is  literally  correct  when 
he  tells  us  that  the  strong  heart  helps  us  to  resist 
temptation.  So  do  healthy  muscles  and  a  sound 
digestion.  To  fill  the  child's  blood  with  four  and  a  half 
million  red  corpuscles  per  cubic  millimeter  and  to 
enrich  it  with  the  oxygen-carrying  haemoglobin  falls 
as  much  within  the  legitimate  field  of  education  as 
instruction  in  the  "Three  R's." 

A  system  of  education  like  our  own,  giving  such  £ 
disproportionate  amount  of  training  to  the  thinking 
activities,  would  have  seemed  preposterous  to  the 
Greeks  or  Romans.  Their  ideal  of  "a  sound  mind  in  a 
sound  body  "  needed  only  the  scientific  basis  of  hygiene 
and  medicine  to  make  their  scheme  of  education  the 
best  the  world  has  seen,  social  and  industrial  condi- 


18    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

tions  considered.  The  religion  of  medieval  Europe 
taught  that  the  salvation  of  the  soul  was  dependent 
upon  the  debasement  of  the  body.  Europe  learned  the 
lesson  only  too  well.  A  frank  exposition  of  the  uni- 
versal neglect  of  personal  and  public  hygiene  in  the 
Middle  Ages  would  bar  this  book  from  the  United 
States  mails. 

Unfortunately,  modern  education  has  been  influ- 
enced in  its  attitude  toward  the  body  by  medieval 
rather  than  by  Greek  and  Roman  ideals.  Physical 
education  has  played  an  insignificant  part  in  modern 
educational  theory  and  still  less  in  educational  prac- 
tice. Our  schools  are  still  what  the  Germans  call  Lern- 
schule.  The  latest  textbooks  on  the  "principles  of 
education  "  all  but  ignore  the  subject,  and  no  compre- 
hensive philosophy  of  physical  education  has  yet  been 
attempted.  In  actual  practice  the  subject  will  not 
receive  the  attention  it  deserves  until  the  educational 
machinery  for  its  control  is  as  complete  and  as  well 
organized  as  our  best  system  for  the  supervision  of 
instruction. 

REFERENCES 

1.  W.  C.  Bagley:  The  Educative  Process,  pp.  1-22. 

2.  Luther  Burbank:  The  Training  of  the  Human  Plant. 
8.  N.  M.  Butler:  The  Meaning  of  Education,  pp.  8-17. 

*4.  John  Fiske:  The  Meaning  of  Infancy. 

5.  E.  N.  Henderson:  A  Textbook  of  the  Principles  of  Education. 
1910.   (Chapters  n  and  m.) 

6.  C.  Herter:  Biological  Aspects  of  Human  Problems.  1912. 

7.  Harold  Home:  The  Philosophy  of  Education,  pp.  18-56. 

8.  M.  V.  O'Shea:  Education  as  Adjustment,  pp.  44-51. 

*9.  M.  V.  O'Shea:  Dynamic  Factors  in  Education,  chapters  IV,  v, 

and  vi. 
10.  G.  E.  Partridge:  The  Genetic  Philosophy  of  Education,  pp.  8-90. 


THE  PHYSICAL  BASIS  OF  EDUCATION      19 

(An  exposition  of  the  views  of  G.  Stanley  Hall  on  the  philo- 
sophical, biological,  and  psychological  foundations  of  educa- 
tion.) 
11.  W.  C.  Ruediger:  The  Principles  of  Education,  chap.  n. 

*12.  Herbert  Spencer:  Education.  (Especially  the  chapter  on  physi- 
cal education.) 

*13.  J.  M.  Tyler:  Growth  and  Education,  chap.  n. 


CHAPTER  III 

THE  GENERAL  LAWS  OF  GROWTH 

Sources  of  data 

A  COMPLETE  census  of  the  physical  conditions  of  a 
nation's  children,  planned  with  special  reference  to  dis- 
covering the  laws  of  growth  and  their  modification  by 
various  environmental  and  social  influences,  would  be 
beyond  comparison  more  valuable  than  all  the  censuses 
of  property  and  population  ever  taken.  But  no  nation 
has  ever  taken  an  inventory  of  its  chief  resource,  the 
raw  material  for  the  new  generation.  Scattered  inves- 
tigations have  been  made,  however,  in  nearly  all  coun- 
tries, involving  altogether  measurements  of  more  than 
150,000  children  of  both  sexes  and  different  ages.  Not 
all  of  these  have  been  taken  with  uniform  procedure  or 
with  sufficient  precautions  to  guard  against  error,  nor 
has  the  statistical  treatment  of  the  data  always  been 
satisfactory. 

To  review  in  detail  even  the  most  important  anthro- 
pometrical  studies  of  growth  would  carry  us  beyond 
the  scope  of  the  present  chapter,  the  purpose  of  which  is 
limited  to  the  presentation  of  the  most  important  laws 
of  growth.1  Growth  statistics  are  likely  to  be  mislead- 

1  The  most  important  of  these  studies  are  those  of  Porter,  Peck- 
ham,  Bowditch,  West,  Boas,  and  MacDonald,  in  America;  Roberts, 
in  England;  Hertel  and  Malling-Hansen,  in  Denmark;  Geissler, 


THE  GENERAL  LAWS  OF  GROWTH         21 

ing  unless  used  with  extreme  caution.  Measurements, 
of  height  and  weight,  especially,  are  of  doubtful  value 
as  guides  for  the  hygiene  of  physical  development.  In 
the  first  place,  these  are  not  simple  phenomena,  but 
complex  resultants  of  many  factors,  the  individual 
significance  of  which  is  in  no  way  elucidated  by  the  nu- 
merous tables  of  established  "norms."  Our  knowledge 
of  growth  needs  to  be  much  more  specific  than  this  and 
should  include  exact  information  relating  to  the  devel- 
opment of  all  the  organs,  the  significant  changes  in 
their  mode  of  functioning  from  birth  to  senescence, 
the  important  abnormalities  of  development,  and  the 
degree  of  resistance  to  various  diseases  resulting  from 
the  ensemble  of  physical  traits  of  each  age.  In  the 
second  place,  the  growth  status  of  the  individual  can 
never  be  evaluated  by  a  table  of  norms  computed 
from  growth  averages.  Each  individual  is  a  law  unto 
himself.  A  school  child  may  be  several  inches  shorter 
and  many  pounds  lighter  than  the  average  for  children 
of  his  age,  race,  and  sex,  while  fully  reaching  the  stand- 
ard which  nature  set  for  him.  Nor  can  we  set  any  lim- 
its above  and  below  which  abnormality  is  reliably  in- 
dicated in  the  individual  child.  Measurements  of  size 
can  give  little  clue  to  the  normality  of  the  processes 
within.  Growth  averages  are,  however,  of  value  as 

Schmid-Monnard,  Engelsperger,  and  Lucy  Hoesch-Ernst,  in  Ger- 
many; Chaumet  and  Binet,  in  France;  Zak  and  Viazemsky,  in  Russia. 
More  detailed  studies  of  the  phenomena  of  growth  will  be  found  in 
the  admirable  summaries  of  Burk,  MacDonald,  and  Hoesch-Ernst, 
while  the  extensive  treatment  of  the  subject  in  Hall's  Adolescence 
is  unequaled  for  suggestive  interpretation. 


82    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

norms  for  comparative  study  of  masses  of  children 
different  in  age,  sex,  race,  social  environment,  etc. 

Of  the  scores  of  available  curves  and  tables  which 
might  be  presented  for  this  purpose,  those  which  fol- 
low are  the  most  reliable  for  use  with  American-born 
children. 


TABLE  1 


•  _ 

• 

Boys 

Girls 

Approzimat 
-  average  age 

Number  of 
observation 

Number  of 
observation! 

Average 
for  each 
year: 
inches 

Absolute 
annual 
increase: 
inches 

Perc'tage 
annual 
increase: 
per  cent 

Average 
for  each 
year: 
inches 

Absolute 
annual 
increase: 
inches 

Perc'tagt 
annual 
increase: 
per  cent 

«} 

1535 

41.7 

1260 

41.3 

2.2 

5.3 

2.0 

4.8 

•} 

3975 

43.9 

3618 

43.3 

2.1 

4.8 

2.4 

5.5 

7} 

5379 

46.0 

4913 

45.7 

2.8 

6.1 

2.0 

4.4 

8} 

5633 

48.8 

5289 

47.7 

1.2 

M 

2.0 

4.2 

81 

5531 

50.0 

5132 

49.7 

1.9 

3.8 

2.0 

4.0 

101 

5151 

51.9 

4827 

51.7 

1.7 

3.3 

2.1 

4.1 

111 

4759 

53.6 

4507 

53.8 

1.8 

3.4 

2.3 

4.3 

121 

4205 

55.4 

4187 

56.1 

2.1 

3.8 

2.4 

4.3 

181 

3573 

57.5 

3411 

•J 

2.5 

4.3 

1.9 

3.2 

141 

2518 

60.0 

2537 

60.4 

2.9 

4.8 

1.2 

2.0 

15} 

1481 

62.9 

1656 

61.6 

2.0 

3.2 

0.6 

1.0 

16} 

753 

64.9 

1171 

62.2 

1.6 

2.5 

0.5 

0.8 

17} 

429 

•J 

790 

62.7 

0.9 

1.4 

18* 

229 

67.4 

Showing  average  American  height,  mathematically  calculated,  by  Dr. 
Franz  Boas,  from  measurements  of  45,151  boj's  and  43,298  girls  in  the 
cities  of  Boston,  St.  Louis,  Milwaukee,  Worcester,  Toronto,  and  Oakland; 
•ho  the  absolute  and  the  percentage  annual  increment  of  same. 


THE  GENERAL  LAWS  OF  GROWTH         23 

TABLE  2 


Boyi 

Girls 

Ag« 

» 

Average 
for  each 
age: 
pounds 

Absolute 
annual 
increase: 
pound* 

Annual 
increase: 
per  cent 

Average 
for  each 
age: 
pounds 

Absolute 
annual 
increase: 
pounds 

Annual 
increase: 
per  cent 

«i 

| 

45.2 

43.4 

7 

49.* 

4.3 

9.5 

47.7 

4.3 

9.9 

8 

54.5 

5.0 

10.1 

52.5 

4.8 

10.0 

9 

59.6 

5.1 

9.3 

57.4 

4.9 

9.3 

10i 

65.4 

5.8 

9.7 

62.9 

5.5 

9.6 

11 

70.7 

5.3 

8.1 

69.5 

6.6 

10.5 

12i 

76.9 

6.2 

8.7 

78.7 

9.2 

13.2 

ISi 

84.8 

7.9 

10.3 

88.7 

10.0 

12.7 

14 

95.2 

10.4 

12.3 

98.3 

9.6 

11.9 

I.'. 

107.4 

12.2 

12.8 

106.7 

8.4 

8.5 

16J 

121.0 

13.6 

12.7 

112.3 

5.6 

5.2 

17 

115.4 

3.1 

2.8 

18j 

114.9 

Inches- 


Showing  the  average  American  weight  mathematically  calculated,  by  M.  de 
Perrpt,  from  the  data  of  about  68,000  children  in  the  cities  of  Boston,  St. 
Louis,  and  Milwaukee;  also  absolute  and  percentage  annual  increases  of  same. 

The  averages  in  the  above  tables  are  graphically 
represented  in  the  curves  given  in  figures  1  and  2. 

Among  the  most 
important  facts  to 
be  gleaned  from 
measurements  of 
growth  are  the  fol- 
lowing: — 

(1)  Absolute  in- 
crement and  per- 
centile  increment. 
The  curves  showing 

these  are  quite  un-   Age"  5  6  .7  8.9  10.11 121314  is  lema 
like.     The   former  no.  j 

refers  tO  the  actual  Showing  Growth  in  Height  and  Weight 


•D 
66 
6i 
62 
60 
58 
56 
54 
52 
50 
48 
46 
44 

A-> 

30 

vs. 

" 

/ 

,> 

f 

/ 

,-- 

/- 

J  <. 

IR 

-S 

;/ 

Lbs. 

''/ 

% 

'tR 

<^ 

120 
110 
100 
90 
80 
70 

J*A 

•£ 

''/ 

/ 

& 

/ 

.*. 

// 

/ 

,£ 

*'  / 

/ 

^ 

^  / 

^ 

/^ 

// 

* 

st 

// 

^ 

X 

-' 

50 

4A 

// 

^ 

^•^ 

lit 

/ 

24    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


ft 
11 
u 

11 

10 
8 
8 

7 
0 

D 

4 
3 
2 
1 

1 

/" 

*"x 

/ 

r  —  " 

| 

A 

J 

1 

# 

V 

-s 

•*v>< 

N^- 

"S 

<> 

\ 

WE 

IG> 

<T 

V 

^ 

' 

A 

* 

2 

3IR 

_s_ 

aj 

& 

^ 

\ 

/^ 

\^- 

,-^ 

\ 

\ 

V 

N. 

s 

N 

H 

EIG 

HT 

\ 

Age  5   6   7    8  9  10  11  12  13141516  17 '18 


gain  in  pounds  or  inches;  the  latter  is  the  ratio  (ex- 
pressed in  percentage)  between  the  gain  in  a  given 

period  of  time  and 
the  total  weight  or 
height.  Although 
growth  is  usually 
described  in  terms 
of  absolute  incre- 
ment, percentile 
increment  would 
be  less  misleading. 
Measured  by  per- 
centile increment, 
FIG.  2  growth  before  birth 

Showing  Annual  Percentile  Increment  of  Growth     is  almost  infinitely 
in  Weight  and  Height 

more  rapid  than  it 

ever  is  again.  In  the  nine  months  preceding  birth, 
weight  increases  nearly  a  billion-fold;  in  all  the  years 
after  birth  only  about  twenty-fold.  As  expressed  by 
Minot  (20),  we  have  already  lost  at  the  time  of  birth 
98  per  cent  of  our  growth  "momentum."  Most  of  that 
which  remains  is  lost  within  the  first  three  years.  Both 
quantitative  and  qualitative  changes  succeed  each  other 
with  ever  increasing  slowness,  like  the  construction  of 
a  wall,  which  first  proceeds  rapidly  and  becomes  more 
and  more  retarded  as  the  distance  from  the  ground 
increases. 

Thus  we  may  be  said  to  approach  senescence  most 
rapidly  in  the  early  years  and  months  and  less  rapidly 
as  life  proceeds.  Because  cell  changes  are  taking  place 


THE   GENERAL  LAWS  OF  GROWTH         25 

so  much  more  rapidly  in  the  first  decade  than  in  the 
second,  more  rapidly  in  the  second  than  in  the  third, 
etc.,  we  may  infer  that  the  educational  possibilities 
(considered  also  in  percentile  terms)  decrease  in  similar 
proportion.  The  mental  progress  made  by  the  child  in 
the  first  year  is  in  this  sense  infinitely  greater  than  that 
of  the  tenth  or  the  twentieth  year.  The  possibilities  of 
modifying  the  growth  and  physiological  functioning  of 
the  various  organs,  including  the  central  nervous  sys- 
tem, rapidly  diminish  as  the  body  cells  assume  their 
stable  and  mature  characters.  For  the  purposes  of 
education  youth  is  more  important  than  manhood  or 
womanhood,  and  childhood  more  precious  than  either. 

(2)  Oscillations  in  growth  rate.  In  general,  the  curves 
for  percentile  increment  in  height  and  weight  show 
a  retardation  of  growth  at  or  before  school  entrance,  a 
slight  acceleration  at  about  7  for  girls  and  8  for  boys, 
a  pre-pubertal  minimum  coming  with  girls  at  9  and 
with  boys  at  11,  followed  by  a  rapid  rise  to  the  maxi- 
mum adolescent  growth  rate  at  the  average  age  of  15 
for  boys  and  12^  to  13  for  girls. 

The  exact  significance  for  education  or  for  hygiene 
of  the  oscillations  in  growth  rate  preceding  puberty 
is  unknown.  As  will  later  be  shown  there  is  reason 
to  believe  that  the  slight  acceleration  at  7  or  8  may 
be  partly  explained  as  a  rebound  from  a  preceding 
retardation  caused  by  the  child's  entering  school.  It 
may  be  influenced  also  by  the  improvement  in  chewing 
surface  which  occurs  at  this  time,  due  to  second  denti- 
tion. It  is  well  established  that  the  period  of  about  6  to 


£8    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

7  is  marked  by  an  increased  frequency  of  nervous  and 
digestive  disturbances. 

The  revolutionary  growth  changes  of  adolescence 
must  be  interpreted  in  relation  to  the  simultaneous 
transition,  no  less  marked,  in  the  instinctive,  emo- 
tional, and  intellectual  life.  It  is  not  by  accident  that 
the  curve  f  or  interest  in  mathematical  puzzles  (Lindley) 
and  the  curve  for  frequency  of  religious  conversions 
(Starbuck)  reach  their  maximum  simultaneously  with 
the  curve  of  growth,  and  that  they  reveal  almost  ex- 
actly the  same  sex  differences.  The  rapidity  of  growth 
at  this  time  suggests  the  desirability  of  bringing  to  bear 
every  possible  influence  that  will  aid  in  implanting  and 
fostering  desirable  traits  of  mind  and  body  before  the 
mold  has  set.  This  principle  is  applicable  alike  to  peda- 
gogy and  to  hygiene.  The  youth  of  18  with  crooked 
spine,  undeveloped  lungs,  and  diseased  heart  is  hardly 
more  hopeful  from  the  point  of  view  of  hygiene  than 
the  juvenile  delinquent  from  the  standpoint  of  morals 
and  religion. 

(3)  Growth  rate  and  resistance  to  disease.  Investiga- 
tions on  this  point  are  somewhat  contradictory,  but 
indicate  on  the  whole  that,  although  the  mortality  rate 
is  lowest  when  the  adolescent  acceleration  is  greatest, 
morbid  conditions  of  both  mind  and  body  are  at  that 
time  most  frequent.  This  is  particularly  true  of  girls. 
It  is  necessary,  however,  to  discriminate  diseases  and 
to  determine  the  curve  of  liability  to  each.  To  lump 
together  diseases  and  complaints  of  every  kind  and 
to  enumerate  them  as  so  many  "illnesses"  or  "de- 


THE  GENERAL  LAWS  OF  GROWTH         27 

fects"  is  of  doubtful  value,  at  best,  and  may  be  mis- 
leading. 

(4)  A  comparison  of  the  curves  for  girls  and  boys 
shows  an  important  difference  between  the  sexes.    The 
girls  reach  their  pre-pubertal  minimum  of  growth  rate 
a  year  or  two  earlier  than  boys  and  their  maximum 
adolescent  rate  about  three  years  earlier.   Rotch  and 
Boas  have  shown  that  the  sex  difference  in  physiologi- 
cal maturity  amounts  to  more  than  a  year  by  the  age  of 
5  years.  The  significance  of  "physiological  age"  dif- 
ferences is  treated  in  chapter  vi. 

(5)  The  relationship   between   physical  and  mental 
growth  is  a  mooted  question.  In  a  sense,  of  course,  men- 
tal growth  must  be  supposed  to  rest  upon  some  kind  of 
physical  basis,  and  the  question  resolves  itself  into  that 
of  the  parallelism  between  growth  in  height  or  weight 
and  development  of  the  neural  structure.  There  is  no 
reason  for  believing  the  parallelism  to  be  perfect,  and  it 
is  a  matter  of  common  observation  that  a  few  children 
are  mentally  advanced  beyond  their  own  individual 
norm  of  height  and  weight  while  others  are  correspond- 
ingly retarded.  This  is  but  another  way  of  saying  that 
height  and  weight  are  not  reliable  indices  of  a  child's 
physiological  maturity. 

For  masses,  however,  the  relationship  undoubtedly 
holds.  Porter's  data  from  34,500  St.  Louis  children 
show  distinctly  that  pupils  of  every  age  who  are  above 
grade  are  taller  and  heavier  than  pupils  of  the  same 
age  who  are  below  grade.  As  an  illustration  of  Porter's 
findings,  the  average  weight  of  11 -year-old  boys  in  the 


28    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

sixth  grade  was  73.34  pounds;  in  the  fifth  grade,  71.29; 
in  the  fourth  grade,  69.24;  in  the  third,  68.12;  in  the 
second,  65.45;  and  in  the  first  grade,  63.5.  The  only 
studies  of  importance  which  fail  to  confirm  this  con- 
clusion are  those  of  Gilbert  and  West,  but  their  method 
of  estimating  intelligence  (by  using  the  teacher's  clas- 
sification of  "good,"  "average,"  or  "dull")  is  unsuit- 
able for  this  purpose  and  in  all  probability  accounts 
for  their  results.  Since  the  large,  dull,  retarded  pupils 
and  the  small,  bright,  advanced  ones  are  found  in  the 
same  class,  the  teacher  is  likely  to  overestimate  the 
dullness  of  the  former  and  the  intelligence  of  the 
latter. 

Roberts's  tables  show  that  the  professional  classes 
of  England  are  distinctly  taller  than  any  other  social 
class,  and  that  the  professional  men  who  are  also  Fel- 
lows of  the  Royal  Society  are  above  the  average  for 
professional  men  in  general.  Numerous  investigations 
have  demonstrated  the  average  inferiority  in  height 
and  weight  of  the  feeble-minded.  Goddard's  figures 
indicate  that  the  average  idiot  begins  to  fall  below  the 
average  normal  child  at  about  7  years,  the  imbecile  at 
about  11,  and  the  moron  at  14.  Shuttleworth  found 
300  idiots  and  imbeciles  to  average  2  inches  below 
normal  at  10  years  and  3  inches  below  at  15  years. 
Bayerthal's  measurements  of  1006  normal  children  of 
Germany  show  an  unmistakable  correlation,  for  masses, 
between  head  circumference  and  intelligence.  All  who 
have  conducted  measurements  of  mentally  defective 
children  agree  in  assigning  them  a  smaller  average 


THE  GENERAL  LAWS  OF  GROWTH         29 

circumference  of  head  than  is  found  among  normal 
children  of  the  same  age. 

The  conclusion,  justified  by  the  data,  that  physical  sM*^ 
superiority  usually  accompanies  mental  superiority,  is  ^v^ 
of  the  greatest  practical  importance  for  education. 
The  opposite  opinion  has  been  very  widespread  and 
has  been  made  the  excuse  for  the  common  practice  of 
restraining  the  school  progress  of  mentally  superior 
children.  In  the  exceptional  case  of  intellectual  pre- 
cocity accompanied  by  physical  weakness,  this  is  the 
wise  course;  but  applied  to  supernormals  as  a  class,  the 
principle  is  unfavorable  to  the  culture  of  genius  and 
inimical  to  social  progress.  Instead  of  restraining  the 
talented  child,  we  should  encourage  him  to  live  up  to 
his  best  possibilities. 

(6)  The  relation  of  pubertal  retardation  to  ultimate 
size.  Another  law  of  growth  somewhat  related  to  the 
above,  and  of  the  greatest  importance  for  hygiene,  is 
that  in  case  of  delayed  puberty  adolescent  acceleration 
is  brief  in  extent  and  leaves  the  individual  below  the 
ultimate  size  of  those  who  reach  puberty  early.  In 
such  children  the  growth  energy  of  adolescence,  though 
rapid,  is  too  quickly  expended  to  permit  the  gain  of  all 
that  has  been  lost.  This  relation,  which  is  quite  the 
reverse  of  common  opinion,  holds  for  races  as  com- 
pared with  one  another  and  for  different  individuals  in 
the  same  race.  Hygiene,  therefore,  should  look  with 
suspicion  upon  all  influences  which  artificially  retard 
growth  in  the  adolescent  or  pre-adolescent  years.1 
1  See  pages  100  and  210. 


80    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

REFERENCES 

1.  Bayerthal:  "Ueber  d.  GegenwSrtigen    Stand  meiner  Unter- 

suchungen  U.  d.  Beziehungen  zwischen  Kopfgrosse  u.  Intelligenz 

im  schulpflichtigen  Alter."    Inter.  Mag.  School  Hygiene,  1911, 

.   pp.  244-61. 

*2.  F.  W.  Boas:  "Growth  of  Toronto  Children."    Kept,  of  U.S. 

Commissioner  of  Education,  1896-97,  p.  1541. 
3.  H.  P.  Bowditch:  "The  Growth  of  Children."    Eighth  Annual 
Kept,  of  Mass.  State  Board  of  Health,  1875.  (See  also  Tenth  and 
Twenty-second  Reports.) 

•4.  F.  D.  Burk:  "Growth  of  Children  in  Height  and  Weight." 
Am.  Jour.  Psych.,  ix,  pp.  253-90.   (Contains  bibliography.) 

5.  E.  Chaumet:  Recherches  sur  la  croissance  des  enfants  des  Scales 
de  Paris.   1906.  pp.  60. 

6.  W.  S.  Christopher:  Measurements  of  Chicago  School  Children, 
Chicago,  1900. 

.  *7.  H.  Donaldson:  The  Growth  of  the  Brain.   1900,  chap.  n. 
*8.  G.  S.  Hall:  Adolescence.  New  York,  1904,  vol.  I,  chap.  I. 
9.  W.  S.  Hall:  "Changes  in  Proportions  of  Human  Body."  Jour. 
Anthr.  Inst.,  Great  Britain  and  Ireland,  1895,  vol.  xxv,  pp. 
21-46. 

10.  W.  W.  Hastings:  Manual  for  Physical  Measurements.   Spring- 
field, Mass.,  1902. 

11.  Paul  Hertz :  Investigation  of  the  Growth  of  Children  in  the  Copen- 
hagen   Elementary    Schools.     Reviewed    in    School    Hygiene, 
August,  1912,  pp.  175-78. 

12.  E.  Hitchcock:  "Comparative  Study  of  Measurements  of  Male 
and  Female  Students  at  Amherst,  Mount  Holyoke,  and  Wel- 
lesley."  Proc.  Am.  Assoc.for  Adv.  of  Phys.  Ed.,  1891,  vol.  37. 

18.  E.  Hitchcock  and  H.  H.  Seeley:  Physical  Measurements  of 

Young  Men.   Boston,  1893. 

*14.  Lucy  Hoesch-Ernst:  Anthropologisch-psychologische  Untersuch- 
ungen  an  Zuricher  Schulkindern.   1906,  pp.  143. 

15.  Irving  King:  "Growth  of  Two  Children."   Jour.  Ed.  Psych., 
May,  1910. 

16.  Koch:  "Ein  Beitrag   zur  Wachsthumsphysiologie  des  Men- 
schen."   Zt.  f.  Schulges.,  1905,  pp.  293-319,  400-16,  457-92. 

*17.  A.   Macdonald:    "Experimental    Study  of  Children."    Rept. 

U.S.   Com.   Ed.,  pp.   97-98,   chapters   xxi-xxv.     (Contains 

bibliography.) 
18.  H.  Malling-Hansen:  Perioden  im  Gewicht  der  Kinder  und  in  der 

Sonnenwarme.  Copenhagen,  1881. 
*19.  E.  Mi 'ii  ma  in  i :  Experimentelle  Pddagogik.   1912,  vol.  I,  pp.  68- 

131. 

20.  Minot:  Age,  Growth,  and  Death.   (See  contents.) 
*21.  G.  W.  Peckham:  "Growth  of  Children."   Sixth  Annual  Rept. 

State  Board  Health  of  Wisconsin,  1881,  pp.  46. 
*22.  W.  F.  Porter:  "Growth  of  St.  Louis  Children."    Trans.  Acad. 

Sci.  of  St.  Louis,  vol.  vi,  p.  263. 


THE  GENERAL  LAWS  OF  GROWTH    31 

23.  C.  F.  Roberts:  Manual  of  Anthropometry.  London,  1878. 

24.  Samosch:  "Ergebnisse  von  Schulkindermessungen  u.  Wagun- 
gen."   Zt.  f.  Schulges.,  1904,  pp.  389  ff. 

25.  Schmidt  u.  Lessenich :  "  Ueber  d.  Beziehungen  zwischen  kb'rper- 
licher  Entwl.  u.  Schulerfolg."  Zt.f.  Schulges.,  1903,  pp.  1-7. 

26.  F.  W.  Smedley:  Report  of  Committee  on  Child-Study.  Forty- 
sixth  Annual  Kept,  of  Board  of  Education.  Chicago,  1899-1900. 
(Child  Study  Report,  No.  2.) 

*27.  J.  M.  Tyler:  Growth  and  Education.   1907.   (See  contents.) 

28.  G.  M.  West:  " Anthropologische  Untersuchungen  an  Schul- 
kindern  in  Worcester,  Mass."   Arch,  fur  Antkrop..  1898. 

29.  H.  Vierordt:  Daten  und  TabeUen.  Jena,  1893. 


CHAPTER  IV 

THE  FACTORS  INFLUENCING  GROWTH 

THE  factors  which  influence  growth  may  be  classed 
into  two  groups:  (a)  Internal  or  hereditary,  including 
racial  heredity,  the  influence  of  immediate  ancestry, 
and  the  fact  of  sex.  (6)  External  or  accidental  influ- 
ences, including  malnutrition,  acute  and  chronic  dis- 
eases, bad  housing,  city  life,  overwork,  lack  of  exercise, 
temperature,  season  of  the  year,  air,  ante-natal  influ- 
ences, etc. 

(a)  The  internal  factors 

Racial  heredity.  Racial  heredity  is  of  prime  import- 
ance in  determining  both  the  ultimate  size  of  the 
individual  and  the  time  of  adolescence.  Growth  norms 
for  the  races  of  northern  Europe,  for  example,  cannot 
be  used  as  standards  for  judging  the  growth  status  of 
Japanese,  South  Italian,  or  Spanish  children.  Stand- 
ards which  represent  averages  of  the  measurements 
obtained  from  mixed  groups  of  Scandinavian,  English, 
Irish,  German,  French,  Italian,  and  Russian  children 
can  have  no  meaning  or  legitimate  use. 

It  was  formerly  believed  that  nearly  all  primitive 
races,  particularly  those  living  in  hot  climates,  are  pre- 
cocious in  their  physical  development.  More  recent 
investigations,  however,  tend  to  discredit  this  belief. 


THE  FACTORS  INFLUENCING  GROWTH    83 

Heche's  study  showed  that  Melanasian  girls  reach  pu- 
berty at  an  average  of  16  to  17  years  ;  that  Melanasian 
children  are  inferior  to  European  children  in  size  at  all 
ages;  that  their  final  size  is  attained  earlier;  and  that 
girls  excel  boys  at  all  ages  preceding  adolescence. 
Baelz  found  the  same  principle  of  retarded  puberty  and 
early  arrest  of  growth  to  hold  also  for  the  Japanese, 
though  to  a  less  degree,  while  children  of  mixed  Japa- 
nese and  European  descent  fell  halfway  between  those 
of.  the  pure  stocks.1  Bobhitt  (2)  found  from  measure- 
ments of  1618  Philippine  children,  ages  6  to  21,  that 
the  pubescent  acceleration  almost  coincides  in  time 
with  that  for  American  children,  but  that  growth  is 
arrested  somewhat  earlier.  Compared  to  the  mascu- 
line standard  for  her  race,  the  Philippine  girl  is  much 
superior  in  power  of  grip  to  the  American  girl.  From 
the  viewpoint  of  hygiene  it  would  be  interesting  to 
know  whether  the  inferiority  of  the  American  girls  is 
inherent,  or  the  result  of  pampering,  indoor  life,  un- 
suitable dress,  etc. 

Family  heredity.  The  influence  of  immediate  an- 
cestry is  also  an  important  determinant  of  growth. 
Children  of  the  same  parents  show  a  high  average 
resemblance  in  intelligence  (brain  growth),  resistance 
to  disease,  and  the  like,  as  well  as  in  height,  weight, 
and  various  other  bodily  dimensions.  Wiener's  meas- 
urements of  his  four  sons  from  infancy  to  maturity 
show  that  the  fourth  son,  who  was  the  offspring  of  a 

1  For  account  of  data  from  Reche  and  Baelz  see  Meumaim's 
Experimentelle  Pddogogik,  2d  edition,  vol.  i,  p.  97. 


34    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

different  mother,  had  a  growth  curve  quite  different 
from  the  other  three. 

According  to  Karl  Pearson  and  his  co-workers  in  the 
Galton  Eugenics  Laboratory,  the  physical  and  mental 
resemblances  of  offspring  to  parent  are  marked  by 
coefficients  of  correlation  falling  for  most  traits  be- 
tween .40  and  .50.  This  means  that  for  any  given  trait 
the  son  may  be  expected  to  differ  from  the  average  from 
40  per  cent  to  50  per  cent  as  much  as  the  father  does. 

The  influence  of  age  of  parents  on  the  growth 
curves  of  children  is  not  known,  but  statistics  of  feeble- 
mindedness indicate  that  heredity  is  most  favorable 
when  the  mother  is  between  the  ages  of  20  and  40,  and 
the  father  between  25  and  50. 

The  relation  of  hygiene  to  eugenics.  It  is  of  the 
greatest  urgency  for  hygiene  that  the  heredity  fac- 
tors, both  racial  and  family,  be  separated  from  the 
influences  of  environment.  It  is  folly  for  hygiene  to 
aim  at  results  which  are  attainable  only  through  the 
agency  of  eugenics.  Hygiene,  for  example,  could  do 
nothing  for  the  cretins1  of  Aosta  beyond  improving 
their  conditions  a  little  by  humanitarian  treatment; 
but  the  defect  was  practically  eradicated  in  a  few 
years  by  segregation  of  the  male  and  female  cretins 
during  reproductive  age.  It  is  possible  also  that  hered- 
ity is  a  more  important  factor  in  the  production  of 
tuberculosis,  cancer,  arterial  sclerosis,  and  many  other 
diseases  than  it  is  usually  believed  to  be.  The  same 
may  hold  also  for  intelligence  and  traits  of  character. 
1  See  p.  55. 


THE  FACTORS  INFLUENCING  GROWTH      35 

Neither  hygiene  nor  eugenics  should  despise  the  scope  of 
the  other;  each  should  confine  its  efforts  to  that  which 
it  is  best  fitted  to  accomplish.  It  would  be  especially 
unfortunate  if  hygiene  should  neglect  the  limitations 
which  a  defective  physical  endowment  places  upon  its 
best  efforts.  On  every  hand  we  see  hygiene  engaged 
in  the  effort  to  patch  up  the  faults  of  heredity,  and 
largely  in  vain.  It  is  certainly  the  duty  of  euihenics x 
to  make  the  best  of  the  raw  material  at  command,  but 
the  euthenist  should  not  be  satisfied  to  work  forever 
with  faulty  material.  Speaking  generally,  it  is  safe  to 
say  that  most  of  the  great  plagues,  both  physical  and 
moral,  which  afflict  mankind  will  never  be  eradicated 
except  by  the  united  efforts  of  hygiene  and  eugenics.* 

(6)  The  external  factors 

The  extent  to  which  external  factors  may  affect 
growth  determines  the  value  of  corrective  and  hygienic 
measures.  If  unfavorable  environment  has  only  minor 
effect  on  normal  growth  tendencies,  then  the  wisest 
precautions  of  hygiene  will  avail  but  little  in  correct- 
ing the  deficiencies  of  growth.  That  external  influ- 
ences are  potent,  however,  is  abundantly  proved  by 
data  from  many  sources,  though  the  exact  extent  to 
which  they  are  operative  is  not  always  clear. 

Influence  of  economic  and  social  conditions.     The 

1  Euthenics  pertains  to  the  favorable  influences  of  environment. 
It  is  contrasted  with  eugenics,  which  refers  to  improvement  of  the 
race  through  application  of  the  laws  of  heredity. 

1  Specific  dat,a  bearing  on  heredity  as  a  factor  in  causing  various 
physical  defects*1  are  reviewed  in  succeeding  chapters. 


36    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

conditions  which  accompany  bad  social  environ- 
ment are  perhaps  the  most  important, — unsuitable 
diet  and  clothing,  crowding,  inadequate  ventilation, 
jverwork,  lack  of  parental  care  as  regards  sleep,  exer- 
cise, personal  habits,  etc.  No  serious  effort  has  ever 
been  made  to  separate  and  measure  the  individual 
effects  of  these  various  factors,  but  the  injury  produced 
by  the  combined  influence  of  all  is  revealed  by  the 
following  representative  findings.1 

TABLE  3 
SocUieiMi i     n     ra    iv     v    vi  vii   vm  rx 

Number  of  cases 150     294     39*     S04     181     293     341       840     66 

Mean  height  (inches) 55      54.      53.5     53.     52.5      52.    51.5    61.      50 

(Class  I  is  highest,  class  IX  lowest  in  social  scale.) 

Superiority  of  children  of  non-laboring  classes  over 
children  of  laboring  classes  is  shown  in  Table  4. 

TABLE  4 

Age 13  14  15  16 

Height  superiority 

(inches) 2.66  3.35  2.89  3.47 

Weight  superiority 

(pounds) 10.33  14.60  13.63  19.64 

Superiority  in  chest  girth 

(inches) 3.17          3.37          3.21  4.11 

Comparison  of  children  of  the  best  and  worst  classes 
in  Edinburgh  showed  a  difference  of  5  pounds  for  boys 
and  10  to  12  pounds  for  girls  in  favor  of  the  better 
classes.  The  difference  in  height  was  2.65  inches  for 
boys  and  3.82  inches  for  girls  (8,  pp.  168  and  210). 
Grouping  72,857  children  of  Glasgow  into  four  classes 
according  to  poverty  gave  a  difference  of  2.5  and  3.8 
inches  for  the  ages  10  and  14  respectively,  and  a 

1  Roberta's  Manual  of  AntfiTOpometry.  London.  1878,  p.  32. 


THE  FACTORS  INFLUENCING  GROWTH    37 

difference  of  3.2  and  5.1  pounds  in  weight  for  the  same 
ages.  Wilson  found  a  difference  of  9.2  pounds  for  boys 
and  6.8  pounds  for  girls  between  the  slum  children  of 
Birmingham  and  the  children  of  a  model  town  in  the 
near  vicinity  (13).  Arkle  found  children  of  the  best 
class  superior  to  those  of  the  poorest  class  by  3.8 
inches  and  6.3  pounds  at  7  years,  and  by  6.5  inches  and 
23  pounds  at  14  years  (1).  Comparing  several  thou- 
sand 14-year-old  children  of  the  artisan  class  with 
children  of  the  most  favored  class,  Dukes  finds  the 
former  inferior  by  3.35  inches  in  height  and  14.59 
pounds  in  weight. 

In  Freiburg,  Germany,  Geissler's  and  Uhlitsche's 
measurements  of  1,874  children  showed  a  superiority 
of  boys  of  the  better  classes  varying  from  2.4  centi- 
meters at  65  years  to  4.7  centimeters  at  13.  The  cor- 
responding figures  for  girls  ranged  from  3.9  centimeters 
at  6^  years  to  5.1  at  13. 

Similar  differences  have  been  discovered  by  many 
other  investigators  in  various  parts  of  Europe  and 
America.  The  contrast  appears  also  in  the  populations 
which  are  the  most  homogenous,  racially,  and  almost  to 
the  same  extent  as  where  the  upper  and  lower  classes 
differ  in  racial  heredity.  In  some  cases  social  class  is 
even  more  potent  in  determining  size  than  race  itself.1 

When  conditions  are  unfavorable  enough  to  affect 

growth  in  height  and  weight  it  is  reasonable  to  suppose 

that  the  effects  would  extend  to  many  of  the  organs  of 

the  body  and  to  their  physiological  functioning.  That 

1  Hoesch-Ernst. 


38    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

such  is  the  case  seems  to  be  well  established.  One  of 
the  main  effects  is  the  delay  of  puberty  and  the  abbre- 
viation of  the  period  of  accelerated  adolescent  growth. 
The  children  of  the  poor,  on  the  average,  reach  pubertj 
late  and  cease  growing  early.  Meyer's  figures  for  6000 
German  girls  showed  a  difference  of  four  fifths  of  a 
year  in  the  average  age  of  puberty  between  the  wealthy 
and  the  poor  classes.  The  extensive  investigations  of 
Key,  Roberts,  and  the  English  Anthropometrical  Com- 
mittee agree  that  the  onset  of  adolescence  is  delayed 
from  one  to  two  years  with  the  lower  classes.  In  such 
cases  the  adolescent  growth  comes  with  a  rush,  is 
abnormally  rapid  for  a  relatively  brief  period,  and 
comes  to  a  standstill  before  the  earlier  losses  have  been 
made  good.  In  every  respect  this  unnatural  course  of 
growth  is  less  favorable  than  a  steady  growth  through  a 
longer  period.  Disturbances  of  physiological  functions, 
disharmonies  of  growth,  physical  defects,  anaemia, 
nervous  instability,  etc.,  are  more  likely  to  occur. 
Statistics  of  medical  inspection  confirm  this  by  show- 
ing a  larger  amount  of  defectiveness  of  almost  every 
kind  among  the  children  of  the  poor. 

Analysis  of  environmental  influences.  What  is  the 
relative  amount  of  influence  exerted  by  the  numer- 
ous factors  which  accompany  poverty?  Science  has 
solved  harder  problems,  but  has  not  yet  set  itself 
seriously  about  the  solution  of  this  one.  Our  univer- 
sities have  accomplished  more  toward  ascertaining 
the  optimum  growth  conditions  for  corn,  wheat,  and 
hogs  than  for  children.  Thus  far  we  have  little  sci- 


THE  FACTORS  INFLUENCING  GROWTH    39 

entific  basis  for  assertions  regarding  the  individual 
effect  upon  healthy  growth  of  insufficient  sleep,  under- 
feeding, inadequate  clothing  and  shelter,  lack  of  oppor- 
tunity for  play,  overwork,  child  labor,  neglect  of  per- 
sonal hygiene,  etc. 

By  classifying  Edinburgh  children  according  as  they 
lived  in  houses  of  one  room,  two,  three,  four,  or  more, 
Mackenzie  was  able  to  show  a  progressive  increase  in 
height  and  weight  with  better  housing  conditions;  but 
this  gives  us  little  clue  to  the  effect  of  housing  itself, 
since  children  who  live  in  one-room  houses  are  also 
at  a  disadvantage  as  regards  sleep,  play,  work,  food, 
parental  care,  etc.  Measurements  showing  the  sub- 
normal size  of  factory  children  in  the  Southern  States 
are  just  as  little  enlightening  as  to  the  influence  of 
child  labor  on  growth.  The  marked  differences  found 
by  Hertz,  Hoesch-Ernst,  and  many  others  between  city 
and  country  children  are  more  decisive  as  to  the  whole- 
some influence  of  rural  life.  Country  children  are  dis- 
tinctly superior  to  city  children  of  the  same  social  class 
in  height,  weight,  chest  girth,  and  power  of  grip.  The 
chest  girth  of  country  girls  approaches  much  nearer  to 
the  average  for  boys  than  is  true  of  girls  in  the  cities. 

Nutrition.  Of  all  the  factors  concerned,  however, 
we  have  reason  to  believe  that  the  nature  and  the 
quantity  of  food  are  the  most  important.  Adequate 
nutrition  is  the  necessary  foundation  of  healthy  growth, 
and  the  lack  of  it  the  most  productive  cause  of  the 
low  vitality  which  favors  tuberculosis  and  certain  other 
diseases.  There  is  hardly  a  defect  found  among  school 


40    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

children  which  is  not  in  greater  or  less  degree  produced 
by  malnutrition.  In  this  category  we  may  include  even 
eye-strain,  dental  defects,  spinal  curvature,  and  nerv- 
ousness, as  well  as  the  infectious  diseases.  Children 
in  open-air  schools  where  feeding  is  practiced  gain 
promptly  and  continuously  in  weight,  and  hold  the 
advantage  gained.1  It  is  impossible,  however,  without 
further  researches,  to  apportion  the  credit  for  this 
among  the  numerous  factors  involved,  —  fresh  air, 
exercise,  decreased  study,  feeding,  sleep,  medical  and 
nurse  attendance,  etc.  That  the  entire  regimen  of  the 
open-air  school  exerts  a  powerful  influence  on  crude 
growth  is  perfectly  well  established,  and  the  influence 
on  the  physiological  functions  appears  to  be  even  more 
pronounced. 

One  further  point  deserves  emphasis.  The  investi- 
gations indicate  that  the  influence  of  poor  nutrition  in 
the  early  years  tends  to  last  throughout  the  growth 
period.  Whether  the  child  will  reach  a  normal  adoles- 
cence and  maturity  is  partly  determined  before  he 
starts  to  school.  As  is  shown  in  chapter  vui,  the  resist- 
1  ance  of  the  permanent  teeth  to  decay  is  partly  deter- 
mined in  the  first  years  of  childhood.  Russow's  growth 
measurements  of  the  same  children  for  eight  years  show 
that  artificially  nourished  children  fall  behind  the 
breast-fed  from  two  to  three  kilograms  in  the  first  year 
and  do  not  catch  up.  It  is  possible,  however,  that 
mothers  who  are  unable  to  nurse  their  children  are 

1  See  chapter  xn  of  Health  Work  in  the  Schools,  Hoag  and 
Tennan. 


THE  FACTORS  INFLUENCING  GROWTH     41 

subnormal  in  physical  endowment  and  that  the  chil- 
dren merely  inherit  a  low-grade  constitution.  Thus,  at  I 
|  every  turn,  we  are  confronted  with  the  baffling  com-  / 
i  plexity  of  the  problems  of  growth. 

The  main  argument  for  breast  feeding  is  the  insur- 
ance it  offers  against  infant  mortality.  The  artificially 
fed  child,  if  it  survives  the  first  year,  is  usually  normal 
in  gross  size,  though  likely  to  be  defective  in  physio- 
logical development,  as  is  shown  by  the  statistics  for 
rickets,  dental  defects,  spinal  curvatures,  etc. 

On  the  whole,  we  may  say  that  that  deprivation, 
malnutrition,  etc.,  must  be  long  continued  in  order  to 
produce  any  permanent  stunting  effects.  Minot  proved 
that  young  guinea  pigs  temporarily  starved  until  they 
were  only  two  thirds  of  the  normal  weight  for  their  age 
were  able  to  make  good  almost  the  entire  loss  with 
return  to  normal  diet.  The  same  is  true  of  temporary 
illnesses,  which,  as  a  rule,  produce  a  prompt  disturb- 
ance of  growth  later  compensated  by  a  corresponding 
acceleration.  The  fact  that  poverty  does  produce  a 
marked  and  permanent  stunting  effect  has,  therefore, 
the  greatest  significance. 

The  evils  of  malnutrition  are  perhaps  best  illustrated 
by  the  effects  of  the  hookworm  disease  upon  the  growth 
of  children.  As  is  well  known,  the  disease  is  caused 
by  the  hookworm  parasite,  a  small  worm  about  a  half- 
inch  in  length,  which  finds  its  way  into  the  alimentary 
tract.  There  it  attaches  itself  in  great  numbers  to 
the  walls  of  the  intestines  and  feeds.  By  frequently 
attaching  and  detaching  themselves  the  parasites 


42     THE  HYGIENE  OF  THE  SCHOOL  CHILD 

cause  hemorrhages,  ulcers,  thickenings  and  degenera- 
tions of  the  intestinal  linings,  hindering  in  this  way 
the  normal  processes  of  digestion  as  well  as  causing  a 
certain  loss  of  blood.  Children  who  have  suffered  for 
some  time  from  the  disease  are  pale,  undersized,  ema^ 
ciated,  mentally  dull,  and  of  low  vitality.  The  number 
of  red  corpuscles  may  fall  to  60  per  cent  of  the  normal 
and  the  haemoglobin  still  lower.  The  liver  and  spleen 
are  enlarged,  and  most  of  the  other  organs  are  affected 
in  one  way  or  another.  The  physiological  development 
may  be  retarded  several  years,  as  is  interestingly  shown 
in  the  radiographs  facing  page  63.  The  condition  in 
the  main  is  one  of  extreme  malnutrition,  though  it  is 
possible  that  the  effects  are  in  some  measure  due  to 
toxins  produced  by  the  parasite  and  injected  into  the 
blood.  In  every  respect  growth  and  development  are 
interfered  with,  and  to  an  extent  proportional  to  the 
number  of  parasites. 

Glandular  influences.  Normal  growth  is  known  to 
be  conditioned  by  the  activity  of  certain  glands,  par- 
ticularly the  thyroid.  If  the  thyroid  is  congenitally 
absent  or  defective,  cretinism  results,  a  condition  of 
mental  defectiveness  with  misshapen  dwarfishness  of 
body.  If  treatment  is  begun  early  enough,  thyroid 
deficiency  may  to  a  certain  extent  be  made  good 
by  a  diet  including  an  artificial  thyroid  preparation 
made  from  the  glands  of  sheep.  It  is  possible  in  this 
way  to  rescue  children  to  a  normal  life  who  otherwise 
would  be  doomed  to  helpless  idiocy.  "Within  six 
weeks  a  poor,  feeble-minded,  toad-like  caricature  of 


THE  FACTORS  INFLUENCING  GROWTH    43 

humanity  may  be  restored  to  mental  and  bodily 
health."  l 

To  be  of  much  avail,  however,  the  diet  must  be  con- 
tinued from  early  infancy  until  growth  is  completed. 
Thyroid  diet  does  not  materially  improve  the  condition 
of  feeble-minded  children  other  than  cretins.  More 
rarely,  certain  organic  defects  are  produced  by  over- 
activity  of  the  thyroid  gland.2 

Growth  rhythms.  Marked  seasonal  influences  on 
growth  were  established  by  the  painstaking  investi- 
gation of  Malling-Hansen  (9),  who  measured  the 
height  of  seventy  boys  daily  for  two  years  and  the 
weight  for  three  years.  For  height,  the  season  of 
maximal  growth  extends  from  the  end  of  March  to 
the  middle  of  August;  the  minimal  period  from 
August  until  the  middle  of  November.  For  weight, 
the  figures  are  almost  exactly  reversed,  maximal 
growth  extending  from  August  to  September  and 
minimal  growth  from  the  end  of  April  to  the  end  of 
July.  This  investigation  was  made  in  Copenhagen. 
Data  are  not  available  to  inform  us  how  the  growth 
rhythm  in  the  South  Temperate  and  Torrid  zones  dif- 
fers from  that  of  the  North  Temperate.  Why  children 
advance  in  height  most  rapidly  in  the  spring  and  early 
summer  and  gain  most  weight  in  the  late  summer  and 
early  fall  is  not  known,  but  the  fact  is  an  important 
one  to  be  kept  in  mind  by  those  who  interpret  growth 

1  Osier,  Practice  of  Medicine,  1909,  p.  771. 
3  Graves's  Disease,  sometimes  treated  by  surgical  removal  of  part 
t)f  the  thyroid  gland. 


44    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

records.  Otherwise,  regimen  may  get  the  credit  or  the 
blame  for  growth  changes  due  to  the  earth's  revolution 
around  the  sun! 

It  is  interesting  to  note  that  the  law  which  states  that 
"rapid  growth  in  height  immediately  precedes  rapid 
growth  in  weight"  holds  for  each  individual  year  as 
well  as  for  the  pubertal  acceleration.  It  is  also  signifi- 
cant that  the  rapid  growth  in  height  is  in  part  coinci- 
dent with  a  period  of  high  fatiguability  and  mental 
sluggishness,  while  the  fall  period  of  rapid  growth  in 
weight  marks  a  rapid  rise  in  the  seasonal  curve  of  the 
power  to  attend.1  Daily,  weekly,  and  monthly  rhythms 
have  also  been  detected,  but  these  are  slight  and  of 
no  special  importance  for  school  hygiene. 

School  influence.  Is  the  influence  of  school  life  suf- 
ficient to  affect  growth  in  height  and  weight?  The  data 
justify  an  affirmative  answer,  particularly  as  regards  the 
period  immediately  following  school  entrance.2  That 
the  initiation  of  the  child  into  the  life  of  the  school  should 
prove  such  a  profound  shock  as  to  affect  the  growth  of 
the  entire  body  forcibly  suggests  the  desirability  of 
reforms  that  will  make  the  transition  from  home  to 
school  more  easy  and  natural.  There  is  no  reason  why 
the  school  should  be  less  healthful  than  the  average 
home.  It  ought  to  be  more  healthful  than  the  average 
home,  and  until  it  is  made  so  the  campaign  for  school 
reform  should  continue.  Open-air  classes  point  the 
ideal  by  demonstrating  that  it  is  as  possible  for  the 
school  to  create  health  as  to  destroy  it.  The  fact  that 
Copenhagen  children  of  to-day  considerably  outrank 

1  See  chapter  xx.  *  See  p.  388. 


THE  FACTORS  INFLUENCING  GROWTH    45 

those  of  thirty  years  ago  both  in  stature  and  weight l 
is  evidence  that  medical  inspection,  shorter  programs, 
school  feeding,  and  other  educational  reforms  have 
there  borne  fruit. 

Pre-natal  influences  on  post-natal  growth  and  devel- 
opment are  little  known.  From  the  evidence  available 
it  appears  that  overwork  and  underfeeding  of  the 
mother  during  pregnancy  reduce  the  size  of  the  off- 
spring at  birth  and  materially  increase  the  probability 
of  death  in  the  first  few  months,  but  that  if  the  early 
dangers  are  safely  weathered  the  child  will  grow  nor- 
mally in  height  and  weight.  Paton  was  able  to  reduce 
the  size  of  guinea  pigs  at  birth  25  per  cent  by  starving 
the  mother  during  pregnancy.  Newman's  important 
work  on  infant  mortality  shows  clearly  that  overwork 
during  pregnancy  is  a  frequent  cause  of  premature 
birth  and  consequent  infant  mortality. 

The  use  of  alcohol  by  the  expectant  mother  is  com- 
monly believed  to  be  productive  of  idiocy  and  of  vari- 
ous kinds  of  disease  and  deformity  in  the  offspring.  The 
recent  researches  of  the  Galton  Eugenics  Laboratory, 
however,  give  no  support  to  this  belief.  On  the  other 
hand,  Stockard  has  plainly  demonstrated  that  paren- 
tal alcoholism  in  guinea  pigs  influences  both  the  num- 
ber and  healthiness  of  the  offspring.  "Forty-two  mat- 
ings  of  alcoholic  guinea  pigs  have  given  only  eighteen 
young  born  alive,  and  of  these  only  seven,  five  of  which 
are  runts,  survived  for  more  than  a  few  weeks;  while 
nine  matings  of  non-alcoholic  guinea  pigs  have  given 
seventeen  young,  all  of  which  have  survived  and  are 
1  See  School  Hygiene,  1912,  pp.  175  jf. 


46    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

normal,  vigorous  individuals.  These  facts  convinc- 
ingly demonstrate  the  detrimental  effects  of  alcohol  on 
the  parental  germ  (of  guinea  pigs)  and  on  the  develop- 
ing offspring"  (11,  p.  297).  This  is  in  agreement  with 
Hodge's  well-known  experiments  on  the  effects  of 
alcohol  upon  dogs. 

The  indirect  injury  which  alcohol  works  upon  chil- 
dren by  depriving  them  of  adequate  food,  clothing, 
shelter,  and  education  is  undisputed,  and  we  are  al- 
ways in  danger  of  mistaking  this  indirect  influence  for 
a  direct  effect  of  alcohol  upon  the  germ  cell  itself. 

REFERENCES 

1.  A.  S.  Arkle:  "The  Physical  Condition  of  Children  attending 
Elementary  Schools."   Lancet,  1907,  p.  127. 

2.  J.  F.  Bobbitt:  "The  Growth  of  Philippine  Children."    Fed. 
Sem.,  1909,  pp.  137-68. 

*3.  F.  Boas:  "The  Growth  of  Children."   Science,  December  13, 

1912,  pp.  815-18. 
*4.  Frederic  Burk:   "The   Influence  of  Physical   Exercise   upon 

Growth."  Am.  Phys.  Ed.  Rev.,  1899,  pp.  340  /. 
*5.  Ethel  M.  Elderton:  "The  Relative  Strength  of  Nurture  and 

Nature."  Eugenics  Laboratory  Lecture  Series,  in,  1909,  p.  40. 

6.  Landsberger:  "Das  Wachsthum  im  Alter  der  Schulpflicht." 
Archiv  f.  Anthropologie,  vol.  xvn,  pp.  229-64. 

7.  Arthur  Macdonald:  "Experimental  Study  of  School  Children." 
Rept.  of  U.S.  Commissioner  of  Education,  1897-98,  pp.  1119  ff. 

8.  W.Leslie  Mackenzie:    The  Medical  Inspection  of  School  Chil- 
dren.   1904,  pp.  139-48  and  204-14. 

9.  P.  Malling-Hansen :  Perioden  im  Gewicht  der  Kinder.   Kopen- 
hagen,  1886.    (Reviewed  by  Burk.) 

10.  T.  Misawa:  "A  Few  Statistical  Facts  from  Japan."  Fed.  Sem., 
1909,  pp.  104-12. 

11.  Charles   R.   Stockard:   "An   Experimental   Study  of   Racial 
Degeneration  in  Mammals  treated  with  Alcohol."   Archives  of 
Internal  Med.,  1912,  pp.  369-98. 

*12.  N.  W.  Wiazemsky :  Influences  des  dijferentsfacteurs  sur  la  crois- 

sance  humaine.    1907,  p.  400. 
IS.  Dr.  H.  B.  Wilson:  "The  Physical  Condition  of  Slum  Children." 

Lancet,  1906,  pp.  549  ff. 
14.  See  also  Burk,  Hall,  Hoesch-Ernst,  and  other  references  given 

at  the  end  of  chapter  in. 


CHAPTER  V 


SOME    PHYSIOLOGICAL    DIFFERENCES    BETWEEN 
CHILDREN  AND  ADULTS 

General  differences 

EVERY  organ  has  its  own  growth  rate  and  its  own 
critical  periods  of 
development. 
Measurements  of 
height  and  weight 
give  us  little  notion 
of  the  complexity 
of  the  processes 
taking  place  with- 
in. Judged  by  size 
alone,  the  child 
might  be  looked 
upon  as  like  the 
adult,  only  small- 
er. Nothing  could 
be  farther  from  the 
truth.  The  child 
is  different  from 
the  adult  in  every 
fiber,  every  blood 
corpuscle,  every 
bone  cell,  and  in 
the  relative  pro- 


PIG.  3 

This  plate  Is  specially  designed  to  show  how  mnch 
the  proportions  of  the  new-born  child  differ  from 
those  of  the  adult.  To  make  this  difference  more 
striking,  the  skeleton  of  a  new-born  child  (A)  and 
that  of  an  adult  (C)  are  here  represented  drawn 
on  different  scales.  (B)  represents  the  new-born 
child  drawn  on  the  same  scale  as  (C).  (From  a 
photograph  by  Prof.  Sanford  published  by  S.  Hall, 
Adolescence,  I.)  — D.  Appleton  &  Co. 


48    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

portions  of  all  his  parts.  His  resistance  to  disease,  his 
powers  of  recuperation,  his  food  and  sleep  require- 
ments are  all  unlike  those  of  the  adult.  He  is  differ- 
ently affected  by  every  element  of  environment  and 
regimen.  Child  hygiene  and  child  physiology  are  far 
from  synonymous  with  the  hygiene  and  physiology  of 
the  adult. 

The  newborn  child  is  largely  trunk  and  head.  Most 
of  his  vital  organs  are  much  nearer  the  adult  size  than 
are  his  height  and  weight.  The  trunk  is  long,  the  head 
is  as  broad  from  side  to  side  as  the  shoulders,  and  the 
legs  are  diminutive.  Plainly  the  little  child  is  a  sessile 
organism  whose  main  business,  judging  from  the  dis- 
proportionate size  and  activity  of  the  vital  organs,  is 
to  keep  alive  and  to  grow.  As  revealed  in  the  figure 
on  page  47,  the  relative  size  of  his  parts  is  such  that 
an  adult  retaining  the  exact  infantile  proportions 
would  strike  us  as  a  misshapen  monster. 

Differences  in  the  Circulatory  System 

The  child's  blood  contains  fewer  red  corpuscles  than 
that  of  the  adult,  and  their  "disintegration  quotient " 1 
is  somewhat  different.  Children  are  more  prone  to 
anaemia  than  adults.  The  white  corpuscles  are  in  all 
somewhat  more  numerous,  but  of  these  relatively  few 
have  germicidal  power.  For  this  and  other  reasons  the 
child's  resistance  to  certain  diseases  is  significantly 
inferior.  As  shown  by  Mouton,  if  the  child  contracts 

1  This  term  refers  to  the  readiness  with  which  the  corpuscles 
yield  up  their  oxygen  to  the  tissues. 


CHILDREN  AND  ADULTS  49 

measles  in  the  first  year  of  life  the  chances  are  about 
one  in  five  that  he  will  not  recover.  From  one  to  three 
or  four  years  the  chances  of  death  are  one  to  twenty- 
five,  and  if  measles  can  be  postponed  until  after  the 
sixth  year  the  probability  of  death  is  reduced  to  about 
one  in  two  hundred  and  fifty.  Whooping-cough  is  an- 
other disease  which  is  more  dangerous  for  the  infant 
than  typhoid  fever  or  smallpox  for  the  adult. 

The  child's  heart,  compared  to  his  arteries,  is  small, 
and  must  beat  with  great  rapidity  to  maintain  the  nor- 
mal pressure  of  blood.  During  growth  the  width  of  the 
aorta  increases  only  three  times;  that  of  the  heart 
twelve  times.  The  adult  ratio  between  heart  and  arte- 
ries is  not  attained  until  the  later  years  of  adolescence, 
previous  to  which  time  all  exercises  and  games  making 
heavy  demands  on  strength  or  endurance  are  danger- 
ous. In  shape,  also,  and  in  its  position  in  the  thoracic 
cavity,  the  child's  heart  is  significantly  different  frou? 
the  adult's. 

The  lymphatic  system  of  the  child  plays  a  much 
greater  role  in  nutrition  and  in  resistance  to  disease 
than  is  true  of  the  adult,  and  since  the  flow  of  lymph 
is  so  largely  dependent  upon  muscular  activity,  seden- 
tary habits  are  particularly  injurious  to  health  in  the 
years  of  childhood.  Associated  with  this  greater  activ- 
ity of  the  lymphatic  system  in  the  early  years  there 
is  a  marked  tendency  to  hypertrophy  of  the  lymphatic 
tissues  (adenoids,  enlarged  tonsils,  etc.)  and  a  special 
liability  to  disease  of  the  lymph  glands. 


50    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

The  digestive  system 

The  digestive  system  of  the  child  is  different  through- 
out its  course  from  that  of  the  adult.  Dentition  is 
not  complete  till  adult  life.  The  mouth  glands  which 
secrete  ptyalin,  the  starch-changing  ferment,  are  en- 
tirely inactive  for  months  after  birth  and  only  gradu- 
ally assume  their  proper  functions.  The  child's  stomach 
is  tubular  and  more  vertical  than  in  the  adult  and  has 
weaker  peristaltic  movements.  The  gastric  secretions 
are  functionally  quite  different  from  those  of  the  adult 
in  that  they  lack  the  power  of  dissolving  the  cell  walls 
in  the  food  and  freeing  the  proteids.  The  intestines, 
likewise,  are  different  in  position,  secretions,  functions, 
and  relative  size.  The  liver  at  birth  is  one  eighteenth 
the  size  of  the  body,  while  with  the  adult,  it  is  one 
thirty-sixth  the  size  of  the  body. 

T*  Metabolism  is  far  more  rapid  in  children  than  in 
adults.  A  child  of  three  years  requires  40  per  cent  as 
much  food  as  the  adult,  though  the  size  of  the  body  is 
less  than  20  per  cent  as  great.  Because  the  surfaces  of 
similar  solids  compare  as  the  squares  and  their  bulk  as 
the  cubes  of  their  linear  dimensions,  it  comes  about  that 
the  child  of  6  has  about  60  per  cent  more  body  surface 
in  proportion  to  weight  than  has  the  adult.  This  in- 
volves far  more  rapid  heat  loss  and  necessitates  rela- 
tively greater  heat  production.  The  infant  consumes 
from  four  to  five  times  as  much  oxygen  as  the  adult  per 
unit  of  weight,  and  the  child  of  6  years  about  twice  as 
much.  The  amount  of  carbon  dioxide  exhaled  is  cor- 
respondingly greater. 


CHILDREN  AND  ADULTS  51 

It  is  not  strange,  therefore,  that  any  disturbance  of 
the  factors  which  influence  metabolism,  such  as  insuffi- 
cient food,  deprivation  from  exercise,  lack  of  fresh  air, 
etc.,  produce  their  ill  effects  upon  the  child  more  quickly 
than  upon  the  adult.  The  child's  reserve  of  energy  is 
small;  his  fatiguability  is  high;  he  is  quickly  brought 
to  exhaustion.  This  is  as  true  for  the  brain  as  for  the 
muscles.  For  the  younger  school  child,  short  periods  of 
work  should  alternate  with  short  periods  of  rest.  Two- 
and  three-hour  school  sessions  without  rest  are  always 
unhygienic  for  young  children,  possibly  also  for  older 
ones.  We  have  only  to  watch  the  rapid  and  spontane- 
ous alternations  of  activities  in  children's  unsupervised 
play  to  find  the  law  which  should  serve  as  the  funda- 
mental guide  in  the  making  of  all  school  programs. 

The  respiratory  system 

Lung  capacity  follows  closely  the  curve  of  weight, 
and  is  therefore  a  valuable  index  of  vitality.  The  ratio  | 
between  lung  capacity  and  weight  is  called  the  "  vital  J 
index."  De  Busk  (3)  finds  the  vital  index  smaller  for 
children  below  grade  than  for  children  not  retarded. 
Although  from  11  to  14  years,  girls  exceed  boys  in 
height  and  weight,  they  fall  below  boys  in  lung  capac- 
ity at  every  age.  This  is  probably  due,  in  part,  to  the 
sedentary  and  indoor  life  led  by  girls,  and  is  very  im- 
portant when  considered  in  relation  to  the  excessive 
mortality  of  adolescent  girls  from  tuberculosis  and 
their  tendency  to  anaemia.  Girls  of  primitive  races, 
and  American  and  European  girls  who  live  in  the  coun- 


52    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


try,  approach  more  nearly  to  the  average  vital  capacity 
of  their  brothers.  The  fact  that  girls  breathe  more  with 
the  upper  part  of  the  chest  than  do  boys  is  traceable 
in  some  degree  to  dress  and  sedentary  habits,  in  part 
to  structural  causes.  Exercise  and  habits  of  breathing 
both  have  an  astonishing  influence  on  vital  capacity, 
which  has  been  known  to  increase  as  much  as  three 
hundred  cubic  centimeters  in  three  months.  Deep 
breathing  helps  to  determine  the  rate  of  oxidation  of 
the  blood,  but  is  less  a  factor  in  this  than  exercise. 

The  size  of  the  lungs,  however,  is  probably  less  re- 
lated to  health  than  is  their  right  use.  The  chief  danger 

lies  in  harboring 
unused  lung  tissue. 
The  importance  of 
right  lung  devel- 
opment and  the 
cultivation  during 
childhood  and  ado- 
lescence of  right 
habits  of  breathing 
and  exercise  can 
hardly  be  over- 
estimated. The  fate 
of  those  who  have  a 
tendency  to  tuber- 
culosis is  usually 
sealed  before  the  close  of  the  adolescent  period.  Smed- 
ley  found  a  direct  correlation  between  vital  capacity 
and  school  progress.1 
(  J  For  relation  of  vital  capacity  to  nasal  obstructions  see  chapter  xn. 


3600 
3400 
3200 
3000 
2800 
2600 
2400 

/ 

/ 

1 

/ 

/ 

/ 

/ 

«7 

^.- 

r'~  " 

2000 
*1800 
1600 
1400 
1200 

1000 
.Age 

/ 

e# 

•* 

<>& 

V 

/ 

/ 

y 

/ 

/ 

, 

•' 

/ 

S 

X- 

•  * 

' 

5  78  9  10  11  12  13  L4  15  16  1J  18 

FIG.  4 

Showing  increase  in  lunf?  capacity.   (From  Srned- 
ley'e  table.) 


CHILDREN  AND  ADULTS  53 

The  accompanying  curve,  based  on  Smedley's  Chi- 
cago study,  gives  the  norms  of  vital  capacity  for  the 
ages  6  to  18. 

The  muscular  system 

On  the  laws  of  muscular  development,  if  the  related 
facts  were  fully  at  our  command,  an  entire  philosophy 
of  education  could  be  based.  The  child's  muscles, 
individually  and  collectively,  differ  from  those  of  the 
adult  in  accuracy,  strength  per  unit  of  cross-section, 
bilateral  symmetry,  ability  to  take  on  training,  deli- 
cacy of  coordinations,  etc.  The  muscular  system  of 
the  newborn  child  is  23.4  per  cent  of  the  weight 
of  the  entire  body,  that  of  the  adult,  43  per  cent. 
Moreover,  the  child's  muscles  contain  relatively  a 
much  greater  proportion  of  water,  and  are  even  more 
inferior  in  function  than  in  size  or  weight. 

The  order  of  development  for  individual  muscles  and 
sets  of  muscles  is  of  greater  significance  for  hygiene  than 
their  growth  considered  en  masse.  The  well-known  law, 
that  voluntary  control  (for  both  rate  and  accuracy)  of 
the  "fundamental "  muscles  develops  before  that  of  the 
"accessory,"  has  immediate  and  obvious  application  in 
manual  and  industrial  training,  drawing,  writing,  play 
instruction,  gymnastics,  sports,  and  in  the  arrangement 
of  the  school  program.  Plays,  manual  exercises,  or 
instruction  of  any  kind  demanding  delicate  coordina- 
tions of  the  accessory  muscles  (the  fingers  and  hands, 
for  example)  should  have  no  place  in  the  kindergarten 
and  need  to  be  subordinated  in  the  first  two  or  three 
years  of  the  grades.  Excessive  employment  of  the 


54    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


& 


accessory  muscles,  to  the  neglect  of  the  fundamental, 
often  gives  rise  to  symptoms  of  nervousness  such  as 
those  associated  with  morbid  precocity.  The  modern 
school  program,  with  its  over-use  of  the  muscles  of  the 
eye  in  reading  and  of  the  hand  in  writing,  coupled  with 
the  still  more  injurious  neglect  of  the  large  muscles 
of  the  arms,  trunk,  and  legs,  constitutes  a  universal 

menace  to  healthy 
growth.  Children's 
bodies,  in  every 
bone,  muscle,  and 
vital  organ,  are 
likely  to  suffer  in 
then*  development 
from  the  sedentary 
regimen  of  the 
school. 

Growth  norms  of 
muscular  strength, 
as  measured  by  power  of  grip,  are  shown  in  the  ac- 
companying curves  from  Smedley. 

The  reader  should  be  reminded  that  the  various  mus- 
cles of  the  legs,  back,  shoulders,  etc.,  have  curves  of 
growth  in  strength  entirely  peculiar  to  themselves,  and 
that  the  curves  for  strength  do  not  parallel  even  ap- 
proximately those  for  accuracy  and  speed.  All  of  this 
is  set  forth  clearly  in  the  admirable  summary  to.  be 
found  in  Hall's  Adolescence. 

In  general,  boys  excel  girls  in  strength  (relative  fc 
weight) ;  also  in  speed  and  accuracy  as  measured  by  the 


K.G. 

'8 
£ 

.42 
•40 
88 
36 
34 
82 
80 
28 
26 
•84 
22 
80 
18 

§ 

12 


Age  6    7    8    -9  10  11  12  13  14  15  16  17  18 
FIG.  5 

Showing  increase  in  strength  of  grip  for  right  hand. 
(From  Bmedley'a  table.) 


CHILDREN  AND  ADULTS  55 

usual  tests.  In  strength  of  grip,  American  girls  fall 
further  below  the  average  for  boys  than  do  the  Philip- 
pine girls. 

Attempts  to  correlate  motor  functions  with  intelli- 
gence in  normal  children  have  given  widely  contra- 
dictory results,  but  the  feeble-minded  as  a  class  are 
decidedly  inferior  to  normal  children  in  strength  of 
grip,  rate  of  tapping,  accuracy  in  tracing  complex  fig- 
ures with  a  pencil,  and  in  the  coordinations  requisite 
for  the  usual  school  work  in  manual  training.  Back- 
ward children  are  especially  retarded  and  uncertain  in 
developing  control  of  the  accessory  muscles. 

Much  has  been  written  about  the  hygienic  aspects  of 
our  system  of  unidextrous  education,  some  hygienists 
believing  that  our  comparative  neglect  of  one  half  of 
the  body  involves  certain  dangers  to  health  and  even  to 
brain  growth.  Unidexterity  certainly  tends  to  produce 
bilateral  asymmetry,  to  favor  one  lung  at  the  expense  of 
the  other,  and  to  bring  about  lateral  curvatures  of  the 
spine.  Indirectly,  through  the  posture,  the  eyes  also 
may  be  influenced.  But  the  advantages  of  specializa- 
tion are  so  great  that  proposals  to  cultivate  perfect 
ambidexterity  in  all  children  cannot  be  taken  seriously. 
The  backward  and  feeble-minded  are  less  often  unidex- 
trous than  normal  children.  This  is  due  chiefly  to 
relatively  lower  development  of  control  of  the  right 
side,  so  that  the  feeble-minded  may  be  said  to  have,  ii 
effect,  two  left  hands. 


M\ 


66    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

The  skeletal  system 

As  regards  the  development  of  the  skeletal  system, 
the  fact  of  greatest  significance  for  hygiene  is  the  ex- 
treme slowness  with  which  ossification  takes  place  and 
the  consequent  possibility  of  deformity  from  incorrect 
posture,  lack  of  exercise,  etc.,  during  the  growth  period. 
Much  that  is  rigid  bone  in  the  adult  is  soft  cartilage  in 
the  child,  and  the  whole  skeletal  system  of  the  latter  is 
plastic  to  a  degree  which  is  rarely  appreciated.1  The 
ossification  of  the  jaws  is  not  complete  till  some  time 
after  puberty,  so  that  severe  deformities  of  the  lower 
part  of  the  face  may  be  caused  or  cured  up  to  this  time. 
The  shape  of  the  entire  head  and  the  proportions  of  all 
its  parts  continue  to  undergo  marked  transformation 
till  well  toward  the  close  of  adolescence.  Even  the 
>  jo^f^\  orbit  of  the  eye  assumes  its  final  shape  only  gradually,  so 
that  the  younger  children  are  prone  to  hyperopia  and 
older  ones  to  myopia.2 

In  the  child  there  is  a  suture  in  the  roof  of  the  middle 
ear  which  permits  easy  connection  by  blood  vessels 
between  the  middle  ear  and  the  dura  mater  membrane 
covering  the  brain.  This  helps  to  explain  the  frequency 
with  which  mastoid  complications  arise  in  the  case  of 
middle-ear  infections  with  children.  Associated  with 
this  is  the  fact  that  the  child's  ear  is  relatively  closer 
to  the  throat  than  the  adult's,  and  that  the  eustachian 
tube,  which  forms  the  connection,  is  straighter  and 
wider,  both  relatively  and  absolutely.  It  is  because  of 
this  short,  straight,  and  broad  road  from  the  throat  to 
1  See  chapter  vu.  *  See  chapter  xrv. 


CHILDREN  AND  ADULTS  57 

the  middle  ear  that  throat  infections  in  children  make 
the  journey  so  readily.1 

The  nervous  system 

Compared  to  the  rest  of  the  body,  the  central  nerv- 
ous system  shows  a  precocious  growth  in  size  and 
weight.  At  birth  the  brain  has  already  attained  about 
one  fourth  of  its  final  size,  and  by  7  years  over  90  per 
cent.  Growth  continues  much  retarded  up  to  about  14, 
and  then  practically  ceases.  But  here,  least  of  all,  does 
weight  give  any  idea  as  to  maturity.  The  cells  of  the 
brain,  though  all  present  in  embryonic,  granule  form 
for  several  months  preceding  birth,  only  gradually 
ripen  into  their  fully  differentiated  structure  and  put 
forth  their  branching  network  of  dendrites.  So  unripe 
is  the  brain  at  birth  that  the  neural  functioning  of  the 
newborn  child  may  be  compared  with  that  of  Golz's 
dogs  whose  brains  had  been  removed.  Only  the  raw, 
instinctive  reflexes  are  present. 

The  acquisition  of  the  medullary  sheath,  which  we 
have  above  spoken  of  as  the  ripening  process,  proceeds 
rapidly  in  the  sensory  and  motor  centers  and  more 
gradually  in  the  frontal  portion,  named  by  Flechsig  the 
"association  centers."  This  includes  almost  two  thirds 
of  the  cerebral  cortex,  which,  together  with  the  middle 
sheath  of  tangential  fibers,  shows  remarkable  and 
important  changes  in  the  cellular  development  of  later 

1  The  most  common  diseases  of  the  bones  during  childhood, 
rickets  and  tuberculosis,  are  discussed  elsewhere.  See  pages  79 
and  129. 


68    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

adolescence,  the  changes  continuing  probably  as  late 
as  40  years.  That  this  is  coincident  with  an  equally 
marked  intellectual  growth  suggests  the  futility  of  the 
premature  culture  of  rationality  and  the  highest  ethi- 
cal traits  of  character.  The  lack  of  judgment,  the  irre- 
sponsibility, and  the  mental  unripeness  of  youth  have 
a  more  material  basis  than  the  mere  lack  of  experience. 
Developed  brain  cells  are  necessary  and  a  rich  network 
of  connections. 

Again  we  see  how  growth  is  capable  of  solving  some 
of  the  most  difficult  pedagogical  problems.  We  cannot 
teach  little  children  to  sit  still,  and  should  not  if  we 
could;  but  if  we  will  only  wait  till  those  higher  centers 
have  developed  which  make  voluntary  inhibition  pos- 
sible, we  shall  find  our  pedagogical  problem  has  van- 
ished. The  youth  can  sit  still  without  being  taught. 
Only  a  little  patience  is  necessary  to  dispose  of  many 
another  pedagogical  dilemma  in  the  same  way. 

But  time  alone  does  not  suffice.  Brain  centers  which 
are  little  used  do  not  develop  normally.  The  visual 
and  auditory  centers  of  Laura  Bridgman's  brain  were 
found,  after  her  death,  to  be  in  the  infantile,  unripe 
condition;  small,  granular,  primitive  cells  with  few 
branches.  The  development  of  the  brain  is  fostered 
best  by  a  play  life  which  is  rich  and  varied  and  by 
educational  exercises  suited  to  its  stage  of  immaturity. 
The  use  of  the  brain  in  varied  physical  and  mental 
activities  improves  its  circulation,  its  nutritional  proc- 
esses, and  therefore  its  finer  development  and  highest 
functioning.  Probably  also  it  delays  the  degenera- 


CHILDREN  AND  ADULTS  59 

tive  processes  of  old  age,  for  senescence,  unfortunately, 
does  not  leave  the  brain  unaffected. 

After  50  or  60,  the  weight  materially  decreases,  the 
neuroglia  —  the  supporting,  non-nervous  connective 
tissue  —  encroaches  more  and  more  upon  the  domains 
of  the  nervous  tissue  proper,  and  the  cells  of  the  latter 
become  heavily  pigmented  and  shrunken  like  the  gan- 
glion cells  of  a  frog  which  have  been  electrically  stim- 
ulated to  the  point  of  exhaustion.1  Many  of  the  cells 
even  disintegrate  and  are  carried  off  as  waste  prod- 
ucts. The  processes  of  decay  seem  to  occur  late  in 
the  life  of  the  mental  worker  and  prematurely  in  those 
whose  labor  is  mostly  physical.  This,  coupled  with 
the  fact  that  cerebral  development  continues  well  on 
into  middle  life,  is  an  added  argument  for  the  estab- 
lishment of  educational  institutions  for  adults;  likewise 
for  such  alterations  of  social  and  industrial  institu- 
tions as  will  enrich  in  any  degree  the  intellectual  life 
of  those  whose  work  is  not  predominantly  mental. 

Lack  of  harmony  and  regularity  in  growth 

Growth  throughout  the  body,  whether  we  compare 
the  organs  of  different  systems  or  different  parts  of 
the  same  system  of  tissues,  progresses  with  the  greatest 
irregularity.  Wherever  we  look  we  fail  to  find  any  such 
thing  as  an  even,  regular,  harmonious  growth.  The 
heart  follows  a  curve  different  from  that  of  the  arteries, 
the  muscles  of  the  leg  different  from  those  of  the  fore- 
arm, the  bone  of  the  upper  leg  different  from  those  of 
1  See  reference  4,  chapter  xvn. 


60    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

the  lower,  etc.  As  stated  by  Hall,  every  organ  has  its 
own  growth  inning.  A  good  illustration  is  the  compari- 
son between  the  growth  of  trunk  and  legs.  In  the  first 
triennium  the  trunk's  percentage  increment  for  length 
is  two  thirds  that  of  the  legs;  in  the  second  triennium, 
one  half;  in  the  third  triennium,  one  fourth;  and  in 
the  fourth  triennium,  again  one  half.  The  excessive 
growth  of  the  legs  from  nine  to  twelve  years  is  not  only 
destructive  of  bodily  grace,  but  may  act  as  a  drain  and 
tax  upon  the  activity  of  the  heart  and  other  organs. 

Most  impressive  also  is  the  lack  of  permanency  in 
the  form,  structures,  and  functions  of  the  child's  or- 
gans. From  first  to  last,  developmental  changes  are 
more  important  than  those  of  mere  growth.  It  is  un- 
safe, a  priori,  to  infer  that  anything  which  is  safe  or 
beneficial  for  the  adult  is  hygienic  for  the  child.  Child 
hygiene,  we  may  repeat,  in  both  its  mental  and  its 
physical  aspects,  must  be  cultivated  as  a  distinct  and 

separate  field. 

REFERENCES 

1.  W.  L.  Bryan:  "The  Development  of  Voluntary  Motor  Abil- 
ity." Am.  Jour.  Psych.,  1892. 

2.  Frederic  Burk:  "  From  Fundamental  to  Accessory  in  the  Devel- 
opment of  the  Nervous  System  and  of  Movements."     Ped. 
Sem.,  1898,  pp.  60. 

3.  B.  W.  De  Busk:  "Height,  Weight,  Vital  Capacity,  and  Retard- 
ation."  Ped.  Sem.,  1913,  pp.  89-92. 

4.  H.  Donaldson:  The  Groicth  of  the  Brain.   1900,  pp.  374. 
*5.  G.  Stanley  Hall:  Adolescence,  vol.  I,  chaps,  u  and  in. 

*6.  Nathan  Oppenheim:  The  Development  of  the  Child.    1898,  pp. 

11-65. 
7.  M.  Probst:  "Gehirn  u.  Seele  des  Kindes."  Samml.  u.  Abh.  uui 

dem  Gebiete  der  Pad  Psych,  u.  Physiol.,  Berlin,  1904. 
*8.  J.  M.  Tyler:  Groicth  and  Education.  (See  contents.) 
9.  Vierordt:  Physiologic  des  Kindesalters. 

10.  See  references  to  chapters  in  and  vi;  also  standard  texts  Ob 
physiologies. 


CHAPTER  VI 

THE  EDUCATIONAL  SIGNIFICANCE  OP 
"PHYSIOLOGICAL  AGE" 

Distinction  between  chronological,  anatomical  and 
physiological  ages 

THE  reader  is  already  familiar  with  the  fact  that  not 
all  children  of  a  given  age  are  equally  advanced  in  a 
physiological  sense.  The  number  of  years  a  child  has 
lived  we  may  designate  as  his  "chronological  age."  In 
contradistinction  to  this,  the  stage  of  maturity  which 
the  child  has  attained  may  be  designated  his  "physio- 
logical age."  The  term  "anatomical  age"  is  some- 
times used  in  reference  to  the  successive  stages  in  the 
anatomical  development  of  the  individual. 

It  is  well  to  keep  clearly  in  mind  this  distinction  be- 
tween chronological  age,  on  the  one  hand,  and  physio- 
logical or  anatomical  age,  on  the  other.  These  run  by 
no  means  a  parallel  course.  A  boy  who  has  lived  six- 
teen years  may  be  no  more  mature,  physiologically, 
than  another  who  has  lived  only  twelve.  Differences 
in  physiological  age  amounting  to  two  or  three  years 
are  extremely  common  in  children  of  the  same  chron- 
ological age.  Given  a  miscellaneous  group  of  boys 
whose  chronological  ages  all  fall  within  one  month  of 
fourteen  years,  there  are  likely  to  be  some  in  the  group 
who  are  two  years  past  the  age  of  puberty  and  others 


62    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

who  will  not  become  pubescent  for  two  or  three  years, 
For  medical,  pedagogical,  industrial,  and  social  reasons 
it  is  sometimes  more  important  to  know  the  physio- 
logical age  than  the  chronological. 

For  opening  up  the  field  in  a  definite  way  we  are 
indebted  chiefly  to  two  important  and  painstaking 
investigations:  (1)  that  of  Rotch  and  Pry  or  on  the 
anatomical  stages  in  skeletal  development,  and  (2) 
Crampton's  study  of  physiological  development  as 
marked  by  pubescence  and  dentition. 

Anatomical  age 

In  studying  the  process  of  ossification  by  means  of 
the  Roentgen  rays,  Rotch  and  Pryor  found  well- 
defined  stages  in  the  transformation  of  cartilaginous 
tissue  into  osseous.  These  stages  always  succeeded  each 
other  in  the  same  order.  The  stages  appeared  most 
clearly  in  the  carpal  bones  and  the  epiphyses  of  the 
hand  and  wrist.  Following  this  suggestive  clue,  Rotch 
made  radiographs,  or  X-ray  pictures,  of  the  wrists  of 
two  hundred  normal  children  of  all  ages  from  birth  to 
14  years.  From  an  analysis  of  the  results  he  marked  off 
thirteen  stages  of  anatomical  development  which  he 
designated  by  the  letters  A,  B,  C,  D,  etc.  These  con- 
stitute in  effect  a  scale  of  norms,  empirically  derived, 
by  reference  to  which  we  may  judge  the  degree  of 
anatomical  development  which  any  given  child  has 
attained.  An  idea  of  the  scale  may  be  gained  by  an 
examination  of  the  plates  facing  this  page. 

Rotch  finds  that  anatomical  development  proceeds 


ft  3    S 
BD    S, 

o  cy    g 


3     I 


PHYSIOLOGICAL  AGE  68 

largely  independently  of  height,  weight,  or  chronologi- 
cal age.  A  12-year-old  child  may  have  a  bone  develop- 
ment corresponding  to  that  of  the  average  10-year-old, 
and  two  10-year-old  boys  of  equal  size  may  show  a 
significant  divergence  in  skeletal  maturity.  Size  and 
real  age  tell  us  nothing  about  a  child's  anatomical  age. 
Rotch  presents  radiographs  of  the  wrists  of  three  boys, 
aged  7,  8  and  9  years  respectively,  who  are  of  exactly 
equal  skeletal  maturity. 

Another  important  point  established  by  Rotch  is 
that  girls  are  more  advanced  than  boys  at  every  age  as 
regards  epiphyseal  development.  This  is  very  different 
from  that  which  obtains  for  height  and  weight,  in  which 
traits  girls  excel  boys  only  from  the  ages  11  to  14.  From 
the  plates  facing  this  page  we  see  how  much  more  ad- 
vanced in  anatomical  age 'a  girl  of  5  years  may  be  than 
her  tmn  brother.  Twins  of  the  same  sex,  however, 
always  show  the  same  grade  of  anatomical  maturity. 

Diseases  which  involve  disturbances  of  nutrition 
influence  anatomical  and  physiological  maturity  much 
more  than  they  affect  height  or  weight.  The  effect  of 
the  hookworm  disease  is  shown  in  another  of  the  platee 
facing  this  page. 

Physiological  age 

The  differences  which  have  been  discovered  in 
physiological,  or  functional,  maturity  corroborate  in  a 
striking  way  the  findings  of  Rotch  and  Pryor.  For  five 
years  Crampton  collected  data  on  the  age  at  which  the 
various  stages  of  pubescence  *  appeared  in  high-school 
1  Three  fairly  definite  stages  were  determined. 


V-A-^jr  V^AJtxvyNXA^ 


*^r 

.    -r 


64    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

boys  of  New  York  City.  These  he  correlated  with 
measurements  of  height,  weight,  grip,  and  school  suc- 
cess. Records  were  secured  from  3835  boys  of  all  ages, 
grades,  and  social  classes  represented  in  the  schools. 
The  results  show  astonishing  differences  of  physio- 
logical maturity  in  boys  of  the  same  chronological  age 
and  the  same  school  class.  The  average  high-school 
class,  particularly  in  the  first  three  grades,  is  a  mixture 
of  pre-pubescents,  pubescents  (those  who  are  under- 


Pre-Pnb. 
Pubescent* 
Pott-Pub., 


12.26     12.76    13.26     13.75    14.25     H.76     16.28    15.75    16.55 


1T.26     17.75     18.86 


FIG.  6 

Percentage  of  each  Pubescence  Sub-Qroup  for  each  Half -Tear  Group.  — CramptOE, 
American  Phytical  Education  Review,  March,  1908. 

going  the  pubescent  transition,  which  lasts  usually  from 
five  to  seven  months),  and  post-pubescents.  The  fun- 
damentally important  question  which  Crampton  raises 
is  whether  the  instruction  meted  out  to  such  a  non- 
homogeneous  group  can  possibly  be  fitted  to  the  intel- 
lectual interests,  the  moral  standards,  the  aesthetic 
appreciations,  or  the  mental  and  physical  endurance  oi 
each  individual  pupil. 


PHYSIOLOGICAL  AGE  65 

The  distribution  of  the  three  stages  of  pubertal 
development  in  Crampton's  3835  boys  is  shown  in 
Fig.  6. 

The  above  curves  show  that  17  per  cent  of  the  boys 
whose  ages  fall  between  12  and  12|  years  have  already 
entered  upon  the  pubertal  transition,  and  that  by  14 
years  the  number  has  increased  to  70  per  cent.  Fur- 
ther, that  about  4  per  cent  of  the  boys  have  completed 
the  transition  by  12i  years,  and  by  15i  years,  about 
80  per  cent.  At  13f  years,  or  about  the  beginning  of 
the  high-school  period,  the  number  of  pre-pubescents, 
pubescents,  and  post-pubescents  is  almost  exactly 
equal. 

The  second  principle  established  by  Crampton  is 
that  height,  weight,  and  strength  correlate  much  more 
closely  with  physiological  than  with  chronological  age. 
Boys  of  14  years,  for  example,  are  tall  or  short,  heavy 
or  light,  strong  or  weak,  according  as  they  have  or 
have  not  reached  pubescence.  This  is  shown  in  the  fol- 
lowing significant  tables:  — 

TABLE  5 

Weight  according  to  physiological  age  (kilograms) 

Age  in  years  Pre-pub.  Pub.  Post-pub. 

13-14  34.9  37.7  43.9 

14-15  85.7  38.7  46.3 

15-16  37.5  39.5  48.5 

TABLE  6 

Weight  of  l!i\  to  15  year  boys  according  to  maturity 

Pre-pubescents  36.76  kilograms 

Pubescents  38.86 

Post-pubescents  .  47.21 


K  >&  ---  A  * 


66    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

The  results  are  similar  to  the  above  for  height  and 
strength.  We  may  say,  therefore,  that  boys  of  13 
who  are  post-pubescent  resemble  in  height,  weight,  and 
strength  post-pubescent  boys  of  15  or  16  much  more 
closely  than  they  resemble  pre-pubescent  boys  of  their 
own  chronological  age.  In  deciding  the  boy's  fitness  for 
a  given  athletic  sport,  or  for  a  certificate  permitting 
him  to  leave  school  to  work  in  a  mill,  or  even  for  in- 
struction of  a  given  grade,  the  crucial  question  is  not 
how  long  he  has  lived,  but  how  far  he  has  proceeded 
toward  maturity.  Furthermore,  in  judging  the  growth 
status  of  an  individual  boy  the  question  is  not  whether 
he  is  as  tall,  as  heavy,  or  as  muscular  as  the  mathe- 
matical average  of  boys  in  general  for  his  age,  but 
whether  he  has  reached  the  physical  standard  which 
his  own  actual  degree  of  maturity  calls  for. 

Scholarship,  also,  seems  to  be  correlated  with  degree 
of  maturity.  Young  pupils  who  have  reached  an  ad- 
vanced grade  are  likely  to  be  found  post-pubescent, 
while  old  pupils  in  the  lowest  grade  are  often  pre- 
pubescent.  Of  the  14  to  14i-year-old  boys  in  the  first 
term  (each  year  is  divided  into  two  terms),  42.9  per 
cent  are  pre-pubescent,  while  of  boys  of  the  same  age 
who  have  reached  the  fourth  and  fifth  terms,  only  16.7 
per  cent  are  pre-pubescent;  68.2  per  cent  of  the  13  to 
13^  year  boys  in  the  first  term  are  pre-pubescent,  as 
against  30  per  cent  of  the  same  age  group  who  have 
reached  the  third  term.  Again,  when  the  percentage 
of  failures  was  calculated  for  each  age  according  to 
degree  of  maturity  it  was  found  that  50  per  cent  more 


PHYSIOLOGICAL  AGE  67 

of  the  pre-pubescent  13-year-old  boys  "failed  "  than  of 
post-pubescent  13-year-olds.  The  corresponding  dif- 
ference for  14  years  was  41  per  cent,  and  for  15 
years,  24  per  cent. 

Crampton  was  able  to  demonstrate  what  previous 
statistics  had  indicated  but  not  established;  namely, 
that  the  later  the  pubescent  transition  arrives  the  more 
rapidly  it  is  hurried  through.  The  speed  of  transition 
from  pre-to  post-pubescence  was  also  found  to  be  much 
more  rapid  in  summer  than  in  winter,  a  fact  which 
demands  reinterpretation  of  such  data  as  those  of 
Malling-Hansen  on  seasonal  variations  in  growth. 

In  a  preliminary  investigation  of  physiological  age 
differences  among  high-school  girls,  Crampton  found 
the  same  relation  of  physiological  age  to  height,  weight, 
and  strength  as  obtained  for  boys. 

Finally,  in  a  third  investigation  of  dentition  among 
934  pupils  of  the  elementary  schools,  Crampton  finds  a 
similar  correlation  of  weight,  height,  and  strength  with 
the  number  of  permanent  teeth  which  have  erupted. 
If  further  data  should  confirm  this,  dentition  would  be 
found  the  most  serviceable  index  of  physiological  ma- 
turity, both  because  of  the  ease  with  which  observa- 
tions may  be  taken  and  because  of  the  long  period 
through  which  the  changes  may  be  noted. 

Conclusions 

The  importance  of  the  distinction  between  physio- 
logical age  and  chronological  age  is  obvious.  We  have 
lately  awakened  to  the  fact  that  each  year  one  child  ID 


vh 
68    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

six  or  seven  fails  of  promotion;  that  the  large  majority 
drop  out  before  reaching  the  high  school;  that  the 
wholesale  elimination  involves  boys  to  a  greater  extent 
than  girls;  that  girls  of  a  given  age  make  better  marks 
in  then-  class  work  and  in  examinations  than  boys  of 
the  same  age;  that  many  weakly  pupils  break  down  in 
the  effort  to  keep  up  with  the  class  in  which  their 
chronological  age  places  them;  —  that  education  from 
bottom  to  top  needs  more  than  anything  else  to  be 
individualized. 

It  is  easy  enough  to  say  that  this  should  be  our  ideal; 
but  how  to  suit  the  instruction  to  the  individual  child 
is  anything  but  easy.  The  value  of  such  investigations 
as  those  cited  above  lies  in  the  suggestions  they  offer 
in  this  line.  They  show  that  children  of  the  same  age 
vary  more  in  maturity  than  we  have  ever  suspected, 
and  that,  although  the  differences  are  accentuated  at 
early  adolescence,  they  are  often  very  marked  in  child- 
hood. They  suggest  that  girls  may  possibly  be  as  ripe 
for  school  at  5  years  as  boys  are  at  6,  and  that  they 
normally  reach  the  high-school  age  some  two  years 
ahead  of  their  brothers.  The  entire  problem  of  the 
identical  co-education  of  the  sexes  will  have  to  be  re- 
viewed in  the  light  of  this  fundamental  physiological 
fact. 

The  investigations  suggest  that  determinations  of 
physiological  and  anatomical  age  by  the  Roentgen 
method,  or  some  other,  might  well  be  invoked  to  help 
decide  doubtful  cases  of  promotion.  For  example, 
let  us  imagine  two  girls  in  a  fourth-grade  class  who  are 


PHYSIOLOGICAL  AGE  69 

a  little  slow  in  their  work  and  about  the  advisability 
of  whose  year-end  promotion  the  teacher  is  in  some 
doubt.  Both  pupils,  let  us  say,  are  not  so  low  in  their 
marks  but  that  they  might  be  expected,  with  consider- 
able extra  effort,  to  carry  the  work  of  the  following 
grade  if  promoted.  But  would  it  be  wise  to  have  the 
child  risk  the  extra  effort  this  would  require?  We  can- 
not answer  this  question  on  the  basis  of  weight,  height, 
grip,  or  the  presence  or  absence  of  external  physical 
defectiveness.  But  if  radiographs  should  reveal  that 
one  of  the  girls  is  a  year  ahead  of  her  age  in  the  physio- 
logical development  and  that  the  other  is  a  year  in 
retard,  there  would  then  be  little  doubt  about  the  wis- 
dom of  risking  promotion  in  the  former  case  and  deny- 
ing it  in  the  latter.  A  few  years  hence  may  see  the 
installation  of  the  Roentgen  apparatus  in  the  hygiene 
departments  of  all  cities  where  school  medical  supervi- 
sion is  practiced.  The  purpose  of  such  work  would  not 
be  merely  that  of  holding  back  the  weak  and  imma- 
ture to  save  them  from  over-pressure;  it  would  be 
equally  concerned  about  permitting  those  of  advanced 
development  to  profit  by  the  advantage  of  maturity 
with  which  nature  has  endowed  them. 
•  It  is  well  to  emphasize,  however,  that  we  do  not  yet 
know  the  precise  degree  to  which  either  pubertal  or 
skeletal  development  is  correlated  with  brain  develop- 
ment or  with  vitality.  The  relation  seems  to  be,  on  the 
whole,  a  fairly  constant  one,  although  Rotch  himself 
admits  possible  discrepancies. 

Closer  investigation  of  the  relations  existing  be- 


70    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

tween  the  anatomical,  physiological,  and  mental  ages 
is  one  of  the  urgent  problems  of  educational  hygiene. 
We  want  to  know  what  the  best  index  of  general  de- 
velopment is.  Theoretically,  Rotch's  method  would 
seem  to  offer  the  best  approach,  since  skeletal  develop- 
ment is  probably  much  less  influenced  by  accidental 
circumstances  of  training,  exercise,  environment,  etc., 
than  are  the  various  physiological  functions.  Yet 
nothing  may  safely  be  taken  for  granted  in  dealing 
with  matters  as  complicated  as  growth  phenomena  are 
known  to  be. 

When  reliable  standards  for  determining  develop- 
mental stages  have  been  worked  out  they  can  be  put  to 
immediate  use  in  diagnosing  athletic  fitness,  in  voca- 
tional guidance,  hi  the  classification  of  pupils  for  man- 
ual work  and  gymnastic  training,  etc.,  as  well  as  in 
problems  relating  to  gradation  for  purposes  of  instruc- 
tion. Society  has  no  moral  right  to  turn  over  the 
weakly  immature  child  of  14  to  the  overtaxing  work  of 
mill  and  factory  on  the  mere  basis  of  so  many  years 
lived. 

Other  problems  which  suggest  themselves  are  the 
bearing  of  physiological  age  differences  on  moral  edu- 
cation, procedure  in  criminal  law,  the  relative  value 
of  male  and  female  teachers  for  various  school  grades, 
the  advisability  of  instituting  the  intermediate  high 
school,  etc.  In  the  light  of  the  well-known  changes 
wrought  by  adolescence  in  the  child's  interests,  and  the 
complete  transvaluation  which  then  becomes  apparent 
in  his  attitude  toward  social  and  moral  questions,  we 


PHYSIOLOGICAL  AGE  71 

may  well  ask  whether  the  same  instruction  can  ever  be 
suited  to  the  needs  of  both  pre-  and  post-pubescents 
whom  our  educational  lockstep  so  frequently  chains 

together. 

REFERENCES 

1.  Rose  Chiles:  "The  Regeneration  of  Child  Life  by  Means  of  the 

Roentgen  Ray."    The  Forum,  August,  1910. 
*2.  Dr.  C.  Ward  Crampton:"  Physiological  Age."  Amer.Phys.Ed. 

Rev.,  March  to  June,  1908. 
8.  Dr.  C.  Ward  Crampton:  "Anatomical  or  Physiological  Age 

versus  Chronological  Age."   Ped.  Sem.,  1908. 
4.  Dr.  C.  Ward  Crampton:  "The  Influence  of  Physiological  Age 

upon  Scholarship."  The  Psychological  Clinic,  1907,  pp.  115-120. 
6.  J.  W.  Pryor:  Bulletins  of  the  State  College  of  Kentucky. 

1905:  "Development  of  the  Bones  of  the  Hand,"  pp.  30. 

1906:  "Ossification  of  Epiphyses  of  the  Hand,"  pp.  35. 

1908:  "The  Chronology  and  Order  of  Ossification  of  the  Bones 

of  the  Human  Carpus,"  pp.  24. 
6.  Dr.  T.  M.  Rotch:  "School  Life  and  its  Relation  to  the  Child's 

Development."  Amer.  Jour.  Med.  Sci.,  1909,  pp.  702-11. 
*7.  Dr.  T.  M.  Rotch:  "Roentgen-Ray  Methods  applied  to  the 

Grading  of  Early  Life."   Am.  Phys.  Ed.  Rev.,  June,  1910. 

8.  Dr.  T.  M.  Rotch:  "Conditions  pertaining  to  the  Safeguarding 
of  Early  Life  from  a  Pediatric  Point  of  View."    N.Y.  Med 
Jour.,  June  18,  1910. 

9.  Dr.  T.  M.  Rotch:  "The  Development  of  the  Bones  in  Earlj- 
Life  studied  by  the  Roentgen  Method."  Trans,  of  Assoc.  oj 
American  Physicians,  1909. 


CHAPTER  VH 

DISORDERS  OF  GROWTH  AND  THE  HYGIENE  OP 
POSTURE 

Written  with  the  assistance  of  Dr.  E.  B.  Hoag 

DISORDERS  of  growth  affect  chiefly  the  bony  skeleton 
and  the  muscles  which  support  and  propel  the  body. 
The  defects  most  commonly  observed  may  be  classi- 
fied as  follows :  — 

A.  Curvatures  of  the  spine. 

1.  Kyphosis.   (Outward  curvature:  round  back.) 

2.  Lordosis.   (Inward  curvature.) 

3.  Scoliosis.   (Lateral  curvature.) 

B.  Other  deformities. 

1.  Pigeon-breast. 

2.  Knock-knee  and  bow-legs. 

3.  Flat-foot. 

The  human  race  in  the  course  of  evolution  has  only 
imperfectly  adapted  itself  to  the  upright  posture.  For 
this  reason,  chiefly,  deformities  of  the  vertebral  col- 
umn, pelvis,  and  legs  are  relatively  common,  since 
these  are  the  structures  most  affected  by  the  shifting 
of  the  center  of  gravity  which  was  brought  about  by  the 
assumption  of  the  upright  posture.  Naturally,  the  in- 
fluence is  greater  during  the  early  periods  of  life  when 
the  tissues  are  soft  and  subject  to  various  nutritional 
disturbances.  The  diseases  which  are  particularly 


v~ 

DISORDERS  OF  GROWTH  75 

likely  to  affect  the  nutrition  and  growth  of  the  build- 
ing material  of  the  body  during  the  rapid  period  of 
growth  are  rickets  and  tuberculosis. 

Spinal  curvature 

Spinal  curvature  ranks  with  eye  defects  as  one  of 
the  most  common  abnormalities  found  among  school 
children.  It  is  safe  to  say  that  from  20  to  30  per  cent  of 
the  entire  enrollment  are  affected,  or  between  four  and 
five  million  in  the  schools  of  the  United  States.  When 
the  slighter  departures  from  symmetry  are  included, 
the  number  runs  very  much  higher.  Probably  as  many 
as  3  to  5  per  cent  have  spinal  curvature  in  a  form  se- 
vere enough  to  menace  general  health. 

One  of  the  best  studies  is  that  of  Scholder,  Weith, 
and  Combe  of  2314  school  children  of  Lausanne.  This 
showed  24.6  per  cent  with  lateral  curvature,  5.8  per 
cent  with  kyphosis  or  lordosis,  and  about  24  per  cent 
with  flat-foot.  In  the  case  of  11.24  per  cent,  the  lateral 
curvature  amounted  to  a  spinal  displacement  of  one 
centimeter  or  more.  There  was  little  difference  be- 
tween girls  and  boys. 

Dr.  Canavan  found  the  following  deformities  among 
2333  supposedly  normal  women  students  of  Wellesley 
College:  — 

TABLE  7 
Percentages  of  orthopedic  defects 

1.  Back,  curvature 35    per  cent 

2.  Shoulders,  uneven 53 

3.  Hips,  uneven 43| 

4.  Legs 

(a)  Knock-kneed 21 


74    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


(6)  Bow-leg  ............  ,  ..............     8£  per  cent 

(c)  Unequal  ..........................       $ 

5.  Ankles  pronated  ......................  70$ 

6.  Longitudinal  arches 

(a)  Flat  ..............................   12 

(6)  High  .............................     5 

7.  Anterior  arches,  flat  ....................  llj 

8.  Toe  joints  enlarged  .....................     3| 

The  results  of  other  important  investigations  are 
presented  in  the  following  table:  — 

TABLE  8 


Spinal  curvatures  of  all  kind* 

Author 

Place 

Number  of 
children 

Boys 

Girls 

Total 

Krug  .    . 

Dresden 

1418 

26% 

22.5% 

25% 

Moscow 

1664  girls 

29 

KaUbadi  '. 

St.  Petersburg 

2333  girls 

— 

20 

Key     .     . 

Stockholm 

3000 

— 

— 

10.8 

Guillaume 

Neuchatel 

731 

18 

41 

29 

Silfwerskiold 

— 

7234  girls 

— 

9.9 

17 

Bruner     .     . 

— 

1081  boys 

17.1  accord- 

ing to  age 

B.T.Mackenzie 

Toronto 

160  high- 

19  (scoliosb 

B.  T.  Mackenzie 

Toronto 

school  girls 
200    college 

24  (scoliosis 

alone) 

boys 

alone) 

B.  T.  Mackenzie 

Toronto 

446   college 

19  (scoliosis 

athletes 

alone) 

Miss  Campbell 

London 

High-school 

— 

22.8  (scolio- 

girls 

sis  alone) 

One  should  be  careful,  however,  to  distinguish  be- 
tween true  spinal  curvature  and  a  mere  faulty  attitude 
due  to  carelessness  or  to  uncertainty  of  posture.  In 
young  children  under  ten  the  muscles  are  sometimes  so 
weak  that  there  is  not  sufficient  muscular  control  to 
keep  the  spine  rigid,  in  which  event  it  often  exhibits  a 
convex  curve  to  the  right  or  left.  Permanent  curvature 
is  designated  as  "fixed"  or  "anatomical,"  to  distin- 
guish it  from  the  "postural"  or  "functional."  Prob- 


DISORDERS  OF  GROWTH  75 

ably  in  less  than  half  of  the  cases  listed  as  spinal  curva- 
ture has  actual  deformity  of  the  bones  taken  place,  and 
in  not  all  of  these  is  displacement  sufficient  to  produce 
serious  injury. 

Spinal  curvatures  sometimes  begin  in  early  child- 
hood, but  more  frequently  between  school  entrance 
and  puberty.  Of  1000  cases  analyzed  by  Roth,  89.7 
per  cent  first  became  evident  between  5  and  17  years, 
and  59.4  per  cent  between  10  and  15.  Silfwerskiold 
finds  10  per  cent  affected  in  the  first  grade;  the  number 
rising  to  17  per  cent  in  the  fourth  grade;  then  dropping 
4o  9.9  per  cent.  The  Lausanne  investigation  gave  the 
following  distribution  according  to  age:  — 

TABLE  9 

Boys  Girls 

8  years  7.8  9.7 

9  16.7  20.1 

10  18.3  21.8 

11  24.2  30.8 

12  27.1  30.2 

13  26.3  37.7 

Kyphosis  (outward  curvature  of  the  spine) 

This  condition  presents  a  round  back,  and  involves 
part  or  all  of  the  vertebral  column.  Sometimes  there 
is  a  sharp  angle  formed,  especially  hi  Pott's  disease. 
The  region  usually  involved  is  the  dorso-lumbar.  The 
condition  is  most  common  in  young  rickety  children, 
although  it  may  occur  in  later  life  as  the  result,  usu- 
ally, of  tuberculosis.  The  common  form  of  kyphosis 
found  in  school  children  is  known  as  "round  shoul- 
ders." In  this  the  outward  curve  is  usually  most 


76    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

pronounced  in  the  middle  of  the  dorsal  part  of  thl 
spine. 

Usually  from  5  to  10  per  cent  of  school  children  have 
round  shoulders.  The  principal  cause  is  muscular 
weakness  which  allows  the  spinal  column  in  this  region 
to  bend  outward,  the  pelvis  to  drop  backward  (lower- 
ing of  the  posterior  part  of  the  pelvis),  and  the  shoul- 
ders to  drop  forward  and  downward.  It  is  easier  for 
the  weak  child  to  assume  the  positions  described  than 
to  maintain  the  normal  posture,  and  he  does  so  with  the 
result  that  kyphosis  becomes  permanently  established. 

Muscular  inactivity  is  the  most  important  factor  in 
the  causation  of  round  shoulders,  and  in  treatment  the 
chief  aim  should  be  to  strengthen  the  muscles  of  the 
shoulders,  back,  and  pelvis  by  appropriate  gymnastic 
exercises. 

Simple  exercises  for  the  correction  of  kyphosis 

(1)  Bending  the  trunk  forward  and  backward. 

(2)  Breathing  exercises. 

Standing  in  an  erect  position  the  child  forces  the  air 
out  of  the  lungs  and  at  the  same  time  the  arms  are 
brought  forward.  The  arms  are  then  gradually  carried 
backward,  while  at  the  same  time  the  child  rises  on  his 
toes  and  takes  a  long  breath. 

(3)  Walking  exercises. 

These  should  be  taken  with  special  attention  to  the 
proper  erect  posture,  the  hips  retracted,  the  shoulders 
back,  and  the  chin  elevated. 

Exercises  with  pulley  weights  while  the  child  is  seated 


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DISORDERS  OF  GROWTH  77 

at  a  distance  of  about  three  feet  are  also  useful.  Mas- 
sage is  excellent,  and  vigorous  outdoor  exercise  is 
indispensable. 

The  use  of  braces  in  cases  of  round  shoulders  should 
nearly  always  be  avoided.  No  ordinary  commercial 
shoulder  brace  is  reliable,  and  every  such  brace  re- 
strains the  action  of  the  muscles.  No  brace  of  any 
description  ought  to  be  used  without  the  advice  of 
an  orthopedic  surgeon.  The  latter  will  rarely  prescribe 
one  except  under  special  and  unusual  conditions.  What 
the  back  and  pelvic  muscles  need  is  not  restriction  but 
increased  exercise  and  activity. 

Lordosis  (inward  curvature  of  the  spine)  "TTVv^ 
This  deformity  is  not  met  so  often  in  school  children 
as  kyphosis  and  latefaTcurvatures.  It  is  caused  usually 
by  some  form  of  hip-joint  disease  or  by  dislocation. 
The  spinal  column  in  lordosis  curves  inward.  The  cor- 
rection consists  in  the  discovery  and  removal  of  the 
cause,  and  for  this  purpose  the  advice  of  a  skilled  sur- 
geon is  always  necessary. 

Scoliosis  (lateral  curvature  of  the  spine) 
Lateral  curvatures  may  be  single  (to  one  side  or  the 
other),  or  there  may  be  two  or  three  lateral  curves.  The 
single  curvatures  are  found  most  frequently  in  young 
children  of  about  4  to  8  years  of  age.  "  Lateral  com- 
pensatory curvatures  appear  usually  at  the  upper  or 
lower  end  of  the  primary  curvature."  Lateral  curva- 
ture not  only  affects  the  spine,  but  also  the  trunk;  con- 
sequently the  hip  projects  on  the  concave  side  (high 


78    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

hip).   The  shoulder  on  the  same  side  is  usually  held 
higher  than  the  other  (high  shoulder). 

Injuries  produced  by  spinal  curvature 

The  significance  of  spinal  curvatures  does  not  lie 
chiefly  in  its  interference  with  the  beauty  and  sym- 
metry of  the  body,  although  this  is  a  matter  well 
worthy  of  our  consideration.  In  severe  cases  the  crowd- 
ing and  displacement  of  internal  organs  may  affect 
unfavorably  the  general  health  of  the  body.  The  organs 
most  concerned  are  the  lungs  and  heart.  The  crowded 
portions  of  the  lungs  fail  to  develop,  and  susceptibility 
to  pulmonary  tuberculosis  is  increased.  Affections  of 
the  apices  (usually  the  right  apex)  of  the  lungs  have 
been  found  in  as  high  as  73  per  cent  of  scoliotic  pa- 
tients. Adhesions  of  the  pleura  are  a  frequent  result. 
The  heart  is  "pushed  upward  and  pressed  against  the 
anterior  chest  wall."  Since  the  breathing  is  superficial, 
the  heart  must  push  a  larger  amount  of  blood  through 
the  lungs  in  order  to  secure  for  the  body  an  adequate 
supply  of  oxygen.  This  extra  demand  on  the  heart 
results  often  in  its  hypertrophy.  The  course  of  the 
aorta  is  somewhat  altered  and  the  blood  pressure 
undergoes  changes.  The  contents  of  the  abdomen  are 
crowded  downward,  and  the  transverse  colon  may  be- 
come almost  vertical.  The  liver,  kidneys,  spleen,  and 
stomach  all  suffer  displacement,  often  with  conse- 
quent injury  to  health.1 

As  regards  the  relation  of  the  school  to  spinal  cur- 

1  See  reference  11,  pp.  89-«0. 


: 

DISORDERS  OF  GROWTH  79 

vature,  expert  opinion  has  undergone  a  radical  change 
in  recent  years.  Noting  the  fact  that  a  large  majority 
of  cases  develop  between  the  ages  6  to  14  years,  and 
coupling  this  with  the  undeniable  frequency  of  incor- 
rect postures  in  the  school,  authorities  were  formerly 
inclined  to  lay  the  blame  mostly  upon  school  life.  La-  J>^ 
ter  studies,  however,  show  that  the  fundamental  cause  . 

rAJ-^"' 

of  nearly  all  severe  spinal  deformities  is  to  be  found  in  '         .    \« 
an  abnormal  or  diseased^  condition  of  thejjojies.   In-   |.  ' 
correct  postural  habits  are  an  aggravating  factor  and 
may  cause  minor  curvatures,  but  they  are  seldom,  if 
ever,  the  sole  cause  of  grave  deformity.  These  are  often 
present  in  children  who  have  never  attended  school. 
Nevertheless  it  is  the  duty  of  the  school  to  do  every- 
thing in  its  power  to  prevent  the  development  of  the 
defect  in  children  who  are  predisposed  to  it.   This  is 
possible  in  various  ways. 

The  most  frequent  cause  of  osseous  deformity  is 
rickets.  This  disease  is  a  special  form  of  infant  mal- 
nutrition affecting  chiefly  the  bones.  The  age  of  onset 
is  generally  between  6  months  and  2  years.  If  severe, 
most  of  the  bones  may  be  affected.  The  head  becomes 
overgrown,  the  joints  large,  the  ribs  are  often  "beaded," 
and  the  bones  of  the  legs  and  trunk  may  become  dis- 
torted under  the  weight  of  the  body  (bow-legs,  knock- 
knees,  etc.). 

The  disease  occurs  among  all  classes,  but  is  more 
common  among  the  poor  of  large  cities.  Gilmour's 
study  of  rickets  among  6470  English  children  showed 
the  following  relation  to  housing  conditions :  — 


80    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

TABLE  10 

Percentage  of  children 

living  in  houses  of          1  room      2  rooms      3  rooms      4  rooms 

Rickety  children 13.4  65.8  18.  2.8 

Non-rickety  children 9.5  66.9  20.3  13.2 

Gilmour  found  evidence  of  rickets  with  23.16  per 
cent  of  school  boys  5  to  14  years  of  age,  and  with 
12.05  per  cent  of  the  girls.  It  is  safe  to  say  that  in  any 
school  population,  not  far  from  10  per  cent  have  been 
affected.  It  is  this  fact,  chiefly,  which  accounts  for  the 
prevalence  of  spinal  curvature,  knock-knees,  bow- 
legs,  pigeon-breast,  etc. 

The  mental  condition  of  rickety  children  averages 
slightly  below  par,  as  shown  by  the  statistics  of  Gil- 
mour.  The  difference,  however,  is  decidedly  less  than 
some  authorities  have  claimed.  Many  rickety  children 
are  extremely  intelligent. 

Tuberculosis  of  the  bone  is  another  frequent  cause 
of  deformities.  The  parts  most  often  attacked  are  the 
spine,  hip,  and  knee.1  If  deformity  is  to  be  prevented, 
it  is  essential  that  treatment  be  begun  at  the  earliest 
^/  /  V  possible  moment.    It  is  stated  by  the 

r  \    best  authorities  that  in  95  per  cent  of 

the  cases  of  tuberculosis  of  the  bone, 
deformity  has  set  in  before  a  diagnosis 
has  been  made. 

Uneven  length  of  the  extremities, 
whether  congenital  or  caused  by  dis- 
ease or  accident,  nearly  always  results 
in  greater  or  less  spinal  curvature,  with 
deformity  of  the  hip  and  shoulder. 
1  See  p.  136. 


T*~*-'Ttt>L-<M 


DISORDERS  OF  GROWTH 


81 


Postural  causes,  though  not  nearly  as  influential 
as  opinion  formerly  held,  are  nevertheless  import- 
ant. Standing  on  one  leg,  if  habitual,  has  some- 
thing of  the  same  effect  as  uneven  extremities. 

Eye  and  ear  defects 
often  result  in  bad  pos- 
ture, and  therefore  fa- 
vor the  development  of 
spinal  curvatures.  Myo- 
pia tends  to  cause  round 
shoulders  because  of  the 
effort  to  get  the  eyes  near 
the  book.  Astigmatism 
causes  functional  lateral 
curvature  from  the  tilt- 
ing of  the  head  to  bring 
the  vertical  strokes  of  the 
print  in  the  diameter  of  FIG.  s  FIG.  9 

One-sided  position    The  correct  position 

clearest  vision.    DeafneSS       from  standing  on       for    recitation    or 

one  foot  —  "  hip-        prolonged  standing 

in  nnp  pur  mav  r>flii«p  tr»r-        PinS   out."  (Mo-       — one  foot  in  ad- 
nay  cause  tor       53*  j  vance  of  the  other€ 

sion  of  the  upper  part  of 

the  spine  from  the  effort  to  listen  with  the  good  ear. 

Desks  which  are  too  high,  too  low,  too  flat,  or  too  far 
from  the  seat  are  sure  to  result  in  faulty  postures. 
The  desk  should  be  adjustable  for  height,  for  slant,  and 
for  sliding  backward  to  afford  complete  rest  for  the 
arms  in  writing. 

Because  of  the  extreme  differences  in  the  height  of 
children  in  the  same  grade,  it  is  essential  that  the  seats 
and  also  the  back-rests  be  adjustable.  Differences  of 


'**>• 


92    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


four  or  five  years  in  age  and  of  fifteen  inches  in  height 
are  commonly  found  among  the  children  of  any  class. 
Stecher's  measurements  of  5000  school  children  show 
that  length  of  legs  bears  no  constant  relation  to  length 
of  trunk;  hence  there  is  no  constant  relation  between 
proper  height  of  seat  and  proper  height  of  desk.  Both 
need  to  be  adjusted  to  fit  the  individual  child  (4,  pp. 
ISO/). 

In  1911  some  forty-seven  cities  in  the  United  States 
were  in  part  provided  with  adjustable  desks.   Few  if 


FIG.  10 

Desk  too  high.    (Alter  Cornell.) 

any  cities  have  a  full  supply  of  them,  and  too  often 
school  officials  neglect  to  make  the  necessary  semi- 
annual adjustments.  Experience  shows  that  most  of 
the  pupils  can  be  approximately  fitted  if  ten  per  cent  of 
the  desks  and  seats  in  each  room  are  adjustable,  pro- 
vided the  remainder  are  divided  among  three  sizes 
appropriate  to  the  grade  in  question. 

The  handwriting  should  be  vertical,  or  nearly  verti- 
cal, in  order  to  insure  good  posture.  Measurements 
have  shown  that  the  average  distance  of  the  child's 


DISORDERS  OF  GROWTH 


83 


eyes  from  the  paper  is  decidedly  less  in  slant  writing 
than  in  vertical.  At  the  same  time,  vertical  writing  is, 
in  itself,  not  a  sufficient  guaranty  of  correct  posture.  In 
all  school  activities  constant  supervision  of  posture 
by  the  teacher  is  necessary.  The  relation  of  writing 
posture  to  spinal  curvatures  —  functional  curvatures, 
at  least  —  is  indicated  by  the  following  facts  presented 
by  Scholder  :  — 

TABLE  11 


Positions  assumed  by  the  children 
in  writing 

Nature  of  the  spinal  curvature* 
found 

Spine  convex  to  the  left  .  . 
Spine  convex  to  the  right. 

.80% 
.  16 

Left  convex  scoliosis.  .  . 
Right  convex  scoliosis  . 

70.3% 
21.1 

Other  postural  causes  include  carrying  books1  or 
papers  always  on  one  side,  improper  handling  of  the 
child  during  infancy,  the  suspension  of  clothing  from 
the  tips  of  the  shoulders,  piano  practice,  etc.  That  im- 
proper postures,  when  habitual,  are  an  important  fac- 
tor in  the  production  of  spinal  curvature  is  well  evi- 
denced by  the  ease  with  which  deformities  are  produced 
artificially.  Savage  tribes  shape  the  heads  of  their 
children  at  will  by  means  of  moderately  tight  bandages. 
The  foot  of  the  Chinese  woman  is  another  illustration. 
Any  type  of  spinal  curvature  can  be  experimentally 
produced  in  dogs  and  rabbits  by  similar  methods. 

It  is  evident,  therefore,  that  if  children  of  abnor- 
mally plastic  bones  are  to  be  prevented  from  develop- 
ing spinal  curvature,  strict  attention  to  posture  will  be 

1  Books  should  be  left  at  school.  Home  study  is  unnecessary  in 
the  grades  below  the  high  school. 


84    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

necessary.  This,  however,  is  not  sufficient.  The  seat, 
the  desk,  and  the  method  of  writing  may  be  ever  so 
ideal,  but  if  the  child  is  kept  too  long  at  his  lessons, 
or  if  the  muscles  of  trunk  and  limbs  are  weakened  by 
too  little  activity  or  by  malnutrition,  a  correct  posture 
cannot  possibly  be  maintained.  It  is  a  dangerous  delu- 
sion to  suppose  that  vertical  penmanship  and  adjust- 
able desks  are  an  efficient  substitute  for  frequent  re- 
cesses, physical  activity,  and  adequate  nutrition.  The 
child's  body  demands  change.  It  will  not  remain,  in- 
definitely, even  in  the  most  "comfortable"  position. 
The  desk  is  really  less  important  than  the  program  of 
study  and  play.  Mental,  as  well  as  physical,  fatigue 
induces  flabbiness  of  muscle  and  the  slump  of  posture.1 
If  spinal  curvatures  are  to  be  cured  or  arrested,  early 
diagnosis  is  essential.  By  the  methods  of  examination 
ordinarily  used  by  school  physicians  in  this  country 
the  milder  cases  are  usually  overlooked.  The  German 
pk-actice  of  stripping  the  child  to  the  waist  is  much 
better.  In  case  of  noticeable  departure  from  body 
symmetry,  exact  tracings  should  be  made  to  deter- 
mine the  exact  nature  and  extent  of  the  curvature. 

Tie  treatment  of  spinal  curvatures 

Spinal  curvatures  can  nearly  always  be  improved  by 
proper  treatment,  and  postural  cases  (cases  in  which 
the  bone  itself  has  not  become  deformed)  can  be  cured 
altogether.  Figure  11  shows  the  improvement  possible 
in  very  severe  cases. 

1  See  reference  to  Kemsies  on  school  desks. 


DISORDERS  OF  GROWTH 


85 


Orthopedic  exercises  may  and  should  be  given  in  the 
public  schools  for  the  benefit  of  children  with  spinal 
deformities.  Special  classes  are  needed  for  this  purpose. 
The  work  should  be  done  by  a  specialist  in  physical 


XX 


FIG.  11 

Four  tracings  illustrating  the  progress  of  an  "  8  "  curve  under  treatment  for  three 
years.  (From  Mackenzie's  "  Exercise  in  Education  and  Medicine.")  —  W.  B. 
Baunders  Co. 

training,  and,  wherever  possible,  should  be  under  the 
general  direction  of  an  orthopedic  surgeon. 

Following  the  example  of  Diisseldorf,  Charlotten- 
burg,  and  Chemnitz,  many  cities  in  Germany  have 
recently  instituted  "orthopedic  classes"  of  this  type. 
In  the  first  class  at  Diisseldorf  35  per  cent  were  cured, 
53  per  cent  were  improved,  and  only  11  per  cent  failed 
to  respond  to  treatment.  The  corresponding  figures  for 
the  second  class  were  51,  34.8,  and  1.4  per  cent.  At 
Chemnitz  there  was  improvement  in  every  case,  ac- 
companied by  a  growth  increase  of  from  one  to  two 
centimeters  in  excess  of  that  which  occurred  in  other 
children  of  the  same  age. 

Classes  for  this  purpose  should  be  small,  preferably 
not  over  twenty  pupils,  and  should  meet  in  the  after- 
noon for  about  one  hour  daily.  To  secure  the  maxi- 
mum results  from  the  special  class  it  is  always  neces- 


86    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

sary  to  enlist  the  cooperation  of  parents  and  teachers; 
the  former,  in  order  to  insure  that  the  child  have  suffi- 
cient food,  sleep,  air,  and  rest;  the  latter,  in  order  to 
guard  against  unsuitable  posture  during  school  work. 
So  successful  have  been  the  pioneer  efforts  in  this 
field,  that  in  1908  the  Prussian  Ministry  of  Education 
issued  a  circular  urging  the  general  adoption  of  the 
orthopedic  class  for  treatment  of  spinal  deformities. 
According  to  Rothfeld,  who  organized  the  work  in 
Chemnitz,  a  city  of  280,000  inhabitants  may  be  ex- 
pected to  have  1500  school  children  who  should  attend 
such  classes.  If  this  is  correct,  the  total  number  in  the 
United  States  must  approximate  360,000. 

Pigeon-breast 

In  pigeon-breast  the  chest  looks  as  if  it  had  been 
pressed  together  from  opposite  sides.  This  results  in  a 
decreased  diameter  of  the  chest  from  side  to  side,  and 
an  increased  diameter  from  front  to  back.  The  chest 
capacity,  however,  is  subnormal.  The  breast-bone  pro- 
jects; hence  the  names  "pigeon-chest,"  "chicken- 
breast,"  "keel-chest,"  etc. 

Pigeon-breast  is  observed  only  in  children  in  whom 
there  is  present  some  unusual  softness  of  the  bones, 
most  often  due  to  rickets.  It  not  infrequently  follows 
whooping-cough  in  rickety  children.  The  deformity 
has  little  or  no  tendency  to  become  worse  during  the 
period  of  growth,  and  the  condition  is  rarely  of  serious 
importance  so  far  as  the  health  is  concerned.  In  many 
of  the  milder  forms  it  disappears  without  any  treat- 


DISORDERS  OF  GROWTH  87 

ment.    In  what  seem  to  be  serious  cases  the  advice 
of  a  surgeon  should  always  be  had. 

Flat-foot 

The  name  "flat-foot"  is  given  to  a  foot  that  has 
given  way  under  the  weight  of  the  body, 
and  rolled  inward,  the  muscles  of  the  leg  not 
being  strong  enough  to  hold  the  foot  in  its 
proper  position.  Other  common  names  for 
this  condition  are  "pronated  foot"  and 
"broken  arch."  The  foot  does  not  really  flat- 
ten out;  the  arch  is  not  really  broken.  The 
muscles  of  the  legs  have  been  strained  bytry- 
ing  to  balance  the  body's  weight  (which  is 

carried  to  the  foot  by  the  shin  bone)  upon   and    Medi- 
cine.")-w. 
the  insecure  foundation  furnished   by  the   £.  saunderu 

Co. 

base  of  the  ordinary  shoe.  The  strain  being 

too  great,  the  muscles  have  weakened  and  the  foot 

has  rolled  inward  under  the  weight  of  the  body. 

By  preventing  the  inward  rolling  of  the  foot,  we  over- 
come the  defect.  This  can  be  done  by  fitting  a  shoe 
that  has  a  proper  base,  a  base  that  is  as  wide  as  the 
foot  and  that  receives  all  the  weight  of  the  body.  We 
do  not  have  to  support  the  arch,  for  the  arch  is  not 
in  danger  of  breaking  down;  but  we  do  need  to  provide 
a  proper  base.  The  metal  device  known  as  an  "arch 
prop,"  or  "instep  supporter,"  is  usually  unnecessary, 
and  used  without  the  advice  of  an  orthopedic  surgeon 
it  may  do  injury. 

It  is  the  shoe  that  is  at  fault,  and  it  is  the  shoe  that 


88    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


must  be  corrected.  The  fault  lies  in  the  lack  of  suffi- 
cient base  for  the  shoe.  The  arch  prop  does  not  correct 
ihis.  When  a  shoemaker  sells  arch  props  to  a  cus- 
tomer, it  is  a  confession  of  weakness.  It  is  as  if  a 
builder  sold  a  house,  and  after  the  deal  was  closed  tried 
to  induce  the  buyer  to  purchase  some  props  or  jack- 
screws  to  hold  the  house  up. 

The  shoe  worn  by  a  flat-footed  person  has  a  char- 
acteristic appearance  :  the  upper  is  bulged  inward  over 
the  heel  and  instep;  the  front 
inner  corner  of  the  heel  is 
worn  off;  there  are  wrinkles 
in  the  vamp  just  behind  the 
ball  ;  the  sole  shows  the  great- 
est wear  along  its  inner  half; 
the  shank  is  pressed  down 
until  its  forward  end  touches 
the  ground  at  each  step,  and 

^he  stitches  often    glVC    away 

at  this  P°mt»  allowing  the 
sole  to  tear  away  from  the  in- 
sole.  The  gait  of  a  flat-footed 
person  is  also  characteristic.  He  walks  with  a  stifi 
ankle  and  with  the  toes  turned  out.  This  is  very 
commonly  observed  in  girls  between  the  ages  of  16 
to  24. 

Every  case  of  flat-foot  is  attended  with  more  or  less 
swelling  of  the  foot  and  leg.  Because  the  ankle  is  held 
stiff,  the  muscles  that  move  it  are  not  brought  into 
action,  consequently  they  do  not  assist  in  the  return  of 


FIG-  13 

Showing  one  of  the  first  sign*  of 
flat-foot,-th«  outward  deflection 
of  the  lower  end  of  the  tendo 


DISORDERS  OF  GROWTH 


89 


the  blood  to  the  larger  veins.  The  blood  then  dilates 
the  veins  of  the  extremities  and  gives  rise  to  swelling 
in  the  hollow  of  the  foot,  around  the  ankle,  and  in  the 
leg.  With  the  swelling  there  is  soreness  and  a  bruised 
feeling.  The  distress  is  not  confined  to  the  foot,  but 
may  extend  to  the  leg,  the  thigh,  or  even  the  back. 
Most  of  the  so-called  rheumatism  of  the  feet  and  limbs 
is  really  the  swelling,  stiffness, 
and  pain  caused  by  flat-foot. 

If  one  foot  is  worse  than  the 
other,  there  will  be  an  uneven- 
ness  of  the  two  sides  of  the 
body.  The  hip  on  the  weaker 
side  will  be  lower  than  the  other, 
the  spine  will  be  twisted,  and 
the  shoulder  on  the  weaker  side 
will  be  higher  than  its  fellow. 
The  level  of  the  body  can  be 
restored  by  fitting  the  feet  to 
shoes  that  will  prevent  rolling 
inward.  While  many  cases  of  flat-foot  can  be  com- 
pletely corrected  by  properly  fitting  shoes,  many 
severe  cases  require  treatment  on  the  part  of  an  or- 
thopedic surgeon. 

Flat-foot  in  children  can  usually  be  recognized  by 
the  heavy  gait,  the  toes  pointing  outward  to  a  marked 
degree,  and  the  soles  of  the  shoes  wearing  out  along 
their  inner  borders.  Such  children  tire  easily,  complain 
of  pain  in  their  legs,  feet,  or  back,  and  ask  to  be  carried 
after  they  have  walked  any  considerable  distance.  The 


d)  (*) 

FIG.  14 

Imprint  of  (1)  arched  foot  and 
(2)  flat  foot.  The  absence  of 
impression  on  the  inner  bor- 
der of  the  normal  footprint 
at  "  A  "  is  due  to  the  eleva- 
tion of  the  foot  by  the  longi- 
tudinal arch.  The  other  arch 
lies  across  the  foot  in  front  of 
this.  (After  Schmidt.) 


90    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

following  points  are  important  in  the  prevention  of 
flat-foot  in  children :  — 

(1)  The  child  must  not  begin  to  walk  until  he  does 
so  of  his  own  accord. 

(2)  No  kind  of  walking  apparatus  must  be  used;  all 
of  them  are  alike  objectionable. 

(3)  The  shoes  must  be  broad  and  must  conform  to  the 
shape  of  the  foot.    Sandals  are  best  for  young  children. 

(4)  Neither  the  toe  muscles  nor  any  other  muscles  of 
the  feet  may  be  constricted  without  weakening  them 
and  risking  the  production  of  flat-foot. 

School  physicians,  teachers,  and  school  nurses  ought 
to  give  careful  attention  to  this  matter  of  flat-foot 
in  children.  Too  commonly  it  is  allowed  to  pass  un- 
noticed, with  the  result  that  as  the  child  grows  older 
the  symptoms  become  progressively  worse.  As  dem- 
onstrated by  Mackenzie  (13),  flat-foot  can  be  cured  or 
greatly  improved  by  massage,  bandaging,  stretching, 
and  appropriate  exercises  for  strengthening  the  muscles. 

Brunner  (quoted  by  Burgerstein)  found  over  10  per 
cent  of  school  children  with  flat-foot.  Mackenzie's 
figures  showed  217  out  of  1000  male  college  students  so 
affected,  while  Dr.  Canavan  discovered  it  in  12  per 
cent  of  2333  female  students  of  Wellesley  College.  It 
is  present  in  a  large  majority  of  scoliotic  children  (76 
per  cent  of  Roth's  1000  cases).  About  3.4  per  cent  of 
the  applicants  for  military  service  in  the  United  States 
are  rejected  for  this  cause.1 

1  The  author  is  indebted  to  Dr.  E.  B.  Hoag  for  the  above  treat- 
ment of  flat-foot. 


DISORDERS  OF  GROWTH  01 

The  education  of  crippled  children 

Too  often  the  crippled  child  has  been  left  to  grow 
up  in  ignorance.  Severe  deformity  is  still  sometimes 
regarded  as  a  legitimate  excuse  for  illiteracy.  What 
town,  village,  or  rural  community  but  harbors  some 
poor  unfortunate,  unable  from  deformity  to  attend 
school,  and  therefore  left  to  his  own  devices  for  educa- 
tion —  an  object  of  curiosity  and  source  of  amusement 
to  those  about  him?  Little  wonder  that  under  such  an 
environment  the  moral  and  social  instincts  sometimes 
suffer  along  with  intelligence,  and  that  the  personality 
of  the  cripple  becomes  warped.  It  is  our  neglect  that 
is  responsible  for  the  phrase  "the  psychology  of  the 
cripple." 

Society  is  at  last  awakening  to  its  educational  re- 
sponsibility to  crippled  children,  and  public  schools  for 
them  are  spreading  with  great  rapidity  in  Germany, 
England,  and  America.  England,  under  the  leadership 
of  Mrs.  Humphry  Ward,  has  outstripped  all  other 
countries  in  this  work.  The  first  public  school  for  crip- 
ples in  London  was  established  by  the  Board  of  Educa- 
tion in  1899.  Since  then  23  "invalid  centers"  have 
been  established  with  an  enrollment  of  1880  pupils. 
Instruction  is  provided  by  the  city,  while  the  expense 
of  meals  is  met  by  the  "Crippled  Children's  Dinner 
Society."  Many  other  cities  of  England  have  followed 
the  example  set  by  London. 

One  of  the  most  famous  of  the  European  schools  of 
this  type  is  the  Danish  school  for  Cripples  at  Copen- 


92    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

hagen.  The  school  is  supported  by  state  grants,  and 
combines  a  residential  school,  a  hospital  department, 
a  day  school,  and  an  "out-patient"  department. 
Emphasis  is  placed  on  vocational  training.  The  trades 
taught  include  woodworking,  brush-making,  bookbind- 
ing, needlework,  boot-mending,  saddlery,  leatherwork, 
etc. 

The  first  public  school  for  cripples  in  the  United 
States  was  opened  hi  New  York  as  late  as  1906.  Since 
then  23  special  classes  have  been  formed  as  a  regular 
part  of  the  day-school  system  of  that  city.  In  all,  about 
450  pupils  are  enrolled.  Twenty  pupils  are  allotted  per 
teacher,  and  the  school  day  is  four  hours  in  length. 
Children  who  are  able  to  do  so  come  to  school  hi  street- 
cars; others  are  transported  in  various  ways.  The  ex- 
penses of  transportation,  nurse  attendance,  etc.,  are 
met  by  the  "Guild  for  Crippled  Children." 

In  1911  Chicago  had  two  schools  for  crippled  chil- 
dren with  an  attendance  of  195.  Massachusetts  is  tht 
only  State  which  supports  an  institution  for  the  cart 
and  education  of  crippled  children.  This  was  estab- 
lished in  1907. 

Though  the  beginning  of  this  interesting  movement 
is  rich  with  promise,  much  remains  to  be  done.  It  is 
estimated  that  in  Germany  there  are  100,000  crippled 
children  eligible  for  this  type  of  school.  Of  these, 
50,000  are  in  need  of  permanent  homes.  But  in  all 
Germany  not  quite  4000  cripples  are  provided  for  in 
the  public  schools.  Of  the  150,000  or  more  crippled 
children  in  the  United  States,  not  1000  are  enjoying 


DISORDERS  OF  GROWTH  98 

the  public-school  advantages  to  which  all  are  enti- 
tled. 

Few  lines  of  educational  endeavor  are  more  profit- 
able than  special  schools  for  cripples.  Nearly  all  crip- 
ples may  be  made  self-supporting  and  rendered  cap- 
able of  leading  happy  and  useful  lives.  The  child  is  not 
only  taught  a  suitable  trade,  but  his  whole  life  is  broad- 
ened and  enriched.  Intellectual  interests  and  normal 
contact  with  other  children  save  him  from  the  empti- 
ness and  pettiness  of  the  ordinary  cripple's  life,  and  the 
saving  grace  of  work  transforms  him. 

In  the  education  of  cripples  a  word  of  warning  would 
not  be  out  of  place.  Hand  training  should  not  too 
much  replace  mind  training.  The  physically  handi- 
capped may,  by  perseverance,  be  taught  miracles  of 
muscular  skill;  but  economy  lies  in  a  maximum  culture 
of  the  crippled  child's  best  faculties.  These,  very  often, 
are  mental.  The  greater  the  weakness  of  the  body,  the 
more  dependent  is  the  child  upon  the  exercise  of  his 
mental  powers. 

Attention,  finally,  should  be  called  to  the  need  for 
public  residential  schools  for  cripples,  such,  for  ex- 
ample, as  that  supported  by  the  city  of  Manchester, 
England.  This  school  is  primarily  for  the  benefit  of 
crippled  children  for  whom  prolonged  surgical  and 
hospital  treatment  is  necessary.  The  patients,  who 
number  about  sixty,  are  chiefly  sufferers  from  rickets, 
infantile  paralysis,  or  tuberculosis  of  the  bone. 

In  many  cases  of  deformity,  particularly  that  result- 
ing from  infantile  paralysis,  regular  treatment  may 


94    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

have  to  be  continued  for  years.  Generally  it  is  impos- 
sible to  insure  that  the  treatment  will  be  rightly  carried 
out  in  the  home.  Nor  is  it  just  to  the  child  that  his 
mental  powers  should  be  allowed  to  atrophy  while  his 
body  is  being  put  in  condition.  The  Manchester  school 
combines  all  the  advantages  of  the  children's  hospital 
with  those  of  a  regular  school.  The  hours  of  instruction 
are  from  9.30  to  12  and  from  1.30  to  3.30.  Most  of  the 
time  is  spent  in  the  open  air.  The  instruction  is  largely 
vocational.  The  average  length  of  stay  is  two  years,  and 
the  cost  per  child  is  less  than  $200  per  year.  Since  the 
school  was  established  in  1905,  98  children  have  been 
sent  out,  most  of  them  so  improved  as  to  be  able  to 
enter  regular  classes  or  to  take  a  secure  place  in  the 
industrial  world.  The  official  report  states  that  rick- 
ety, distorted  cripples,  unable  to  walk,  are  discharged 
after  two  or  three  years  with  sound,  straight  limbs 
requiring  no  artificial  support  and  showing  no  tendency 
to  relapse.  There  are  yet  no  residential  schools  of  this 
type  supported  by  any  municipality  in  this  country, 
although  it  is  said  there  are  18,000  children  in  the  city 
of  New  York  alone  undergoing  prolonged  treatment 
in  children's  hospitals. 

The  obligations  of  society  to  the  crippled  child  are 
perfectly  clear,  and  the  educational  activities  we  have 
just  sketched  are  of  the  greatest  promise.  The  move- 
ment should  continue  until  the  educational  rights  of 
crippled  children  are  everywhere  recognized  and  given 
first  claim  to  attention. 


A  VERY  SERVICEABLE  TEST  FOR  POSTURE 

From  Bancroft's  "  Posture  of  School  Children,"  by  permission  of  The  Macraillan  Com 
pany,  New  York. 


DISORDERS  OF  GROWTH 


TABLE  12 

General  survey  of  leading  deformities 


Kyphosis 
(outward  curvature) 

Lordosis 
(inward  curvature) 

Scoliosis 
(lateral  curvature) 

Flat-foot 

Signs 

Signs 

Signs 

Sign» 

Round  back 

Back  curving  in- 

Inequality in 

Ankle  turned 

Round  shoulders 

ward 

height  of 

inward 

Angular  projection 
in  the  dorso-lum- 

Protruding  abdo- 
men.   (Often 

shoulders 
One  hip  higher 

Shoe  heel  worn 
out  ou  inner 

bar  region 

present  with 

than  the  other 

side 

Wing  shoulder 

kyphosis) 

Wrinkling  of 

Stiff,  inelastic 

blades 

clothes  on  one 

gait 

Flat  chest 

side  of  the 

Toes  turn  out- 

back 

ward  in  walk- 

Barefoot-track 

test 

Causes 

Causes 

Causes 

Causes 

Muscular  weakness 

Hip-joint  disease 

Weak  muscles 

Muscular 

Rapid  growth 
Rickets 
Tuberculosis  of  spine 

Dislocation  of  hip 
Rickets 

Malnutrition 
Rickets 
Tuberculosis  of 

weakness 
Improperly  fitting 
shoes 

Forward  posture  in 
school,  etc. 

spine  or  hip 
Some  form  of 

Jumping 

paralysis 

Faulty  postures 

REFERENCES 

1.  Gladys  Abbott:  "A  Study  of  Posture  in  School  as  affected  by 

Schoolroom  Lighting."  Am.  Phys.  Ed.  Rev.,  March,  1905. 
*2.  Jessie  H.  Bancroft:  The  Posture  of  School  Children.   1913,  pp. 
327. 

3.  Dr.  Biesalski:  "Was  kbnnen  die  Schularzte  zur  Behandlung 
der  skoliotischen  Volksschulkinder  tun  ?  "  Zt.  f.  Schulges.,  1906, 
pp.  545-50  and  610-27. 

4.  W.  S.  Cornell:  The  Health  and  Medical  Inspection  of  School 
Children.   1912,  pp.  461-78. 

5.  R.  C.  Elmslie:  "Minor  Defects  of  Adolescence  in  Relation  to 
Medical  Inspection."   School  Hygiene.   1910,  pp.  616-30. 

6.  A.  Gilmour:  "Mental  Condition  in  Rickets."   School  Hygiene, 
1912,  pp.  6-16. 

*7.  J.  E.  Goldthwaite:  Relation  of  Posture  to  Human  Efficiency. 

Boston,  1909,  pp.  38. 

8.  J.  E.  Goldthwaite:  In  Pyle's  Personal  Hygiene,  fifth  edition. 
1912.    (Chapter  on  "The  Body-Posture.") 


96    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

9.  Fritz  Hartel:  "Die  Skoliose  eine  Volkskrankheit."  Inter.  Mag. 

Sch.  Hyg.,  vol.  in,  1907,  pp.  324-54. 
10.  Dr.  Leonard:  "Das OrthopadischeTurnen  in  die  Schule."  Zt.f. 

Schulges.,  1910,  pp.  713-24  and  807-13. 

*11.  R.  W.  Lovett:  Lateral  Curvature  of  the  Spine  and  Round  Shoul- 
ders. 1907,  pp.  188.  New  Edition,  1912. 

12.  R.  W.  Lovett:  "Relation  of  School  Life  to  Lateral  Curvature  of 
the  Spine."   Proc.  1912  Cong.  Am.  Sch.  Hyg.  Assoc.,  1912,  pp. 
174-79. 
*1S.  R.  Tait  McKenzie:  Exercise  in  Education  and  Medicine.   1910, 

pp.  406.    (Especially  chapters  xv  to  xvin.) 

14.  Eliza  Mosher:  Health  and  Happiness;  A  Message  for  Girls.  1912. 
*15.  Eliza  Mosher:  "Habitual  Postures  in  School  Children."    Ed. 
Rev.,  1897,  pp.  261-72. 

16.  George  Muller:  Spinal  Curvatures  and  Awkward  Deportment. 
London,  1894,  pp.  88.    (Chiefly  of  historical  value.) 

17.  Bernard  Roth:  Treatment  of  Lateral  Curvature.  Second  edition, 
1899,  pp.  141.   (Chiefly  of  historical  value.) 

18.  Dr.   Rothfeld:   "Flinf   Jahre   orthopadisches  Schulturnen  in 
Chemnitz."   Zt.f.  Schulges.,  1911,  pp.  249-62  and  344-56. 

*19.  Scholder,  Weith,  and  Combe:  "Les  deviations  de  la  colonne 
vertebrale  dans  les  6coles  de  Lausanne."  Jahrb.  der  Schweizer- 
ischen  Gesellschaft  f.  Schulhygiene,  1901. 

20.  Dr.  Schulthess:  Schule  u.  Ruckgratsverkrummung.  Voss,  Leipzig, 

1902. 

21.  J.  S.  Kellet  Smith:  "Lateral  Curvature  and  Short  Leg."  The 
Child,  1913,  pp.  411-17. 

22.  F.  Wohrizck:"SonderschulenfurSkoliotische."  Zt.f.  Schulges., 
1907,  pp.  175-79. 

23.  (See  Standard  texts  on  School  Hygiene:  also  on  Children's 
Diseases.) 

The  education  of  crippled  children 

24.  Konrad  Biesalski:  " Krtippelschulen."  Zt.  f.  Schulges..  1911, 
pp.  411-21. 

25.  R.  C.  Elmslie:  The  Care  of  Crippled  and  Invalid  Children  in 
Schools.  Not  dated,  pp.  50.  School  Hygiene  Pub.  Co.,  London. 
(Very  valuable.) 

*26.  Evelyn  M.  Goldsmith:  "The  Education  of  Crippled  Children." 

In  Monroe's  Encyclopedia  of  Education.   1912,  vol.  n. 
27.  D.  C.  McMurtrie:  "The  Education  of  Crippled  Children  in  the 
United  States."   School  Hygiene,  1912,  pp.  17-23;  vol.  iv,  pp. 
129-62. 

*28.  Leonard   Rosenfeld:     "liber  Krilppelschule."    First  Interna- 
tional Congress  for  School  Hygiene,  vol.  rv,  pp.  129-70. 
29.  F.  Shrubsall:  "The  Danish  Cripple  School  System."    School 
Hygiene,  1912,  pp.  172-73. 

*30.  E.  D.  Telford:  The  Problem  of  the  Crippled  School  Child.  Lon- 
don, 1910,  pp.  32.  (An  account  of  the  Manchester  Residential 
School.) 


DISORDERS  OF  GROWTH  97 


*81.  Leo  Burgerstein:  In  Burger  stein  u.  Netolitzky'a  Handbook  der 

Schulhygiene,  1912,  pp.  62-69. 
*32.  F.  B.  Dresslar:  In  Monroe's  Encyclopedia  of  Education,  1912, 

vol.  n. 
33.  Frederick  J.  Cotton:  "School  Furniture  for  Boston  Schools." 

Am.  Phys.  Ed.  Rev.,  December,  1904.   (Very  valuable.) 
*34.  Kemsies   u.    Hirschlaff:   "Arbeits   u.   Ruhehaltungen   in  der 

Schulbank."  Zt.f.  Schidges.,  1912,  pp.  409-24  and  497-509. 


CHAPTER  VIH 

MALNUTRITION  IN  SCHOOL  CHILDREN 

The  importance  of  nutrition 

"MALNUTRITION"  is  a  much  broader  term  than 
"starvation."  The  latter  is  ordinarily  used  to  desig- 
nate the  condition  of  extreme  insufficiency  of  food.  But 
malnutrition  is  probably  half  as  prevalent  among  the 
well-to-do  as  among  the  poor.  A  child  may  be  ill-nour- 
ished either  because  of  insufficiency  of  food,  because  of 
inherent  weakness  of  the  power  of  food  assimilation, 
because  of  disturbances  of  the  digestive  processes,  or 
because  the  food  has  been  improperly  chosen  or  unsuit- 
ably prepared.  Accordingly,  the  educational  and  other 
sociological  aspects  of  our  problem  are  just  as  import- 
ant as  the  economic. 

Nutrition  is  fundamental  for  all  lines  of  child  devel- 
opment. The  stability  of  the  bodily  structure  is  de- 
pendent upon  the  materials  that  make  it  up.  Malnu- 
trition during  the  period  of  growth  leaves  permanent 
flaws  in  the  constitution.  It  is  responsible  for  more 
degeneracy  than  is  alcohol.  Alcoholism  is  often  nothing 
but  a  symptom  of  disturbed  nutrition.  The  greatest 
problem  throughout  childhood  is  that  of  feeding. 
,  The  influence  of  food  on  growth  in  height  and  weight 
has  already  been  set  forth,  and  has  been  shown  to  rank 
in  importance  with  the  influence  of  race.  In  the  chil- 


MALNUTRITION  IN  SCHOOL  CHILDREN      99 

dren  of  the  poor,  puberty  is  reached  late  and  the  pu- 
bertal  growth  acceleration  is  slurred  over.  Resistance 
to  infection  is  markedly  decreased.  Ill-nourished  chil- 
dren "take"  everything.  Malnutrition  is  almost  the 
invariable  forerunner  of  tuberculosis,  chorea,  and  many 
other  diseases.  It  also  renders  recovery  less  certain 
and  increases  the  liability  to  relapse. 

The  effects  of  severe  malnutrition  are  well  illustrated 
by  the  hookworm  disease.  The  hookworm  victim  of 
26  years  may  present  a  state  of  sexual  and  skeletal 
development  normal  to  that  of  the  14-year-old  child. 
Children  of  14  years  present  the  general  appearance  of 
10-year-olds.  Growth  and  development  are  interfered 
with  and  to  an  extent  proportional  to  the  number  of 
the  parasites.  The  disease  is  extremely  prevalent  hi 
some  areas  of  the  Southern  States,  sometimes  from  50 
to  60  per  cent  of  the  children  being  affected. 

The  effect  of  malnutrition  on  mental  development  is 
probably  very  great,  though  difficult  to  measure  accu- 
rately. Malnutrition  is  from  two  to  three  times  as  com- 
mon among  children  who  are  badly  retarded  mentally 
as  among  those  making  average  progress.  Plans  for  the 
feeding  of  school  children  have  in  this  country  usually 
originated  among  the  teachers  of  special  classes,  and 
increased  mental  alertness  is  always  a  marked  sequel 
of  school  feeding.  Bean  has  reported  a  case  of  perma- 
nent peculiarity  of  mental  development  resulting 
apparently  from  severe  and  prolonged  malnutrition 
during  the  pre-school  period  (3).  Dr.  Warner  found 
from  his  examinations  of  100,000  London  school  chit 


100    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

dren  that  28  per  cent  of  the  dull  pupils  were  ill-nour- 
ished, and  conversely  that  almost  the  same  percentage 
of  the  ill-nourished  were  dull.  Macmillan  and  Bodine 
found  that  of  2100  retarded  children,  54.6  percent  were 
suffering  from  malnutrition.  It  is  probable,  however, 
that  the  mental  effects  are  less  marked  than  the  phys- 
ical. The  tissues  do  not  suffer  equally,  but  roughly  in 
proportion  to  their  importance.  Starvation  may  re- 
duce the  weight  of  the  muscles  nearly  50  per  cent  while 
effecting  a  loss  of  only  1.1  per  cent  upon  the  central 
nervous  system  (31).  The  survival  value  of  such  an 
arrangement  is  obvious. 

Are  many  children  ill-nourished  ? 

In  order  to  estimate  the  importance  of  malnutrition 
as  a  problem  in  child  hygiene  it  is  necessary  to  gain  an 
idea  of  its  prevalence.  But  difficulty  arises  here  because 
of  the  absence  of  any  definite  and  universally  accepted 
criterion.  Perfect  nutrition  gradually  shades  off  into 
slightly  unsatisfactory  nutrition,  and  the  latter  into 
extreme  malnutrition.  Some  medical  examiners  report 
only  the  latter;  others  report  all  cases  which  present 
symptoms  of  subnormality.  If  this  is  borne  in  mind, 
such  disagreement  as  may  be  found  in  the  statistics 
about  to  be  presented  will  not  be  misleading. 

Perhaps  the  most  thorough  investigation  yet  made 
in  this  country  is  that  of  Macmillan  and  Bodine  (9). 
This  investigation  included  an  examination  of  10,000 
children  in  one  of  the  poorer  districts  of  Chicago.  The 
proportion  suffering  from  malnutrition  varied  from 


MALNUTRITION  IN  SCHOOL  CHILDREN    101 


nearly  16  per  cent  among  kindergarten  children  to 
about  6  per  cent  above  the  fourth  grade.  These  figures 
avowedly  include  only  the  extreme  cases.  Harring- 
ton's report  on  the  90,000  school  children  of  Boston 
places  the  number  of  anaemic  and  ill-nourished  at  ap- 
proximately 5000,  or  nearly  6  per  cent.  Of  2000  chil- 
dren examined  in  certain  New  York  schools,  in  1909, 
more  than  13  per  cent  were  reported  ill-nourished. 
Robert  Hunter  and  John  Spargo  (40)  estimate 
that  there  are  probably  2,000,000  school  children  in 
the  United  States  suffering  from  malnutrition. 

The  report  of  the  Royal  Commission  estimated  that 
9  per  cent  of  the  school  children  of  Aberdeen,  Scotland, 
are  under-nourished,  and  29.8  per  cent  of  those  in 
Edinburgh.  Eicholz  estimated  the  ill-nourished  school 
children  of  London  at  16  per  cent,  and  Dr.  Macnamara 
at  10  to  15  per  cent. 

Dr.  Crowley,  of  Bradford,  England,  classified  817 
school  children  according  to  nutrition  into  three 
classes.  The  following  table  represents  his  results. 
Group  A  represents  pupils  from  the  better  districts 
of  the  city;  Group  B  those  from  the  poorest. 

TABLE  13 


Nutrition 

Infant  School 

Upper  School 

Group  A 

Group  B 

Group  A 

Group  B 

Good  

55% 
36 
29 

31% 
35 
34 

68% 
25 

7 

24% 
43 
33 

Below  normal  

Poor  or  very  poor  

102    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


The  following  table  from  Dr.  Arkle  shows  the  condi- 
tions of  nutrition  found  among  1026  boys  and  921  girls 
in  the  secondary  schools  of  Liverpool.  The  columns 
A,  B,  and  C  correspond  to  schools  attended  by  the 
children  of  the  best  classes,  the  middle  classes,  and  the 
poorest  classes  respectively. 

TABLE  14 


Boys 

Girl* 

A 

B 

C 

A 

B 

C 

Good  

80.  % 

28.5% 

10.5% 

91  6% 

65.7% 

16.9% 

Fair  

17.8 

60.1 

35.3 

8.1 

33.9 

52.5 

Poor  

1.3 

9.7 

48.6 

0.0 

.7 

28.6 

Very  bad  

.7 

2.4 

0.0 

.0 

1.8 

In  Germany,  Wimmenauer  reports  (1912)  an  excep- 
tionally careful  study  of  the  nutrition  of  1942  school 
children  in  Mannheim.  His  results  are  summarized 
as  follows:  — 

TABLE  15 


Nutrition 

Boys 

GirU 

Good  

18.8  per  cent 

31.2  per  cent 

Medium  

62.6 

55. 

Bad  

18.6 

13.8 

One  of  the  most  thorough  studies  yet  made  is  that  o\ 
Gaspar  (16)  of  8037  children,  of  Stuttgart,  6  to  14  years 
of  age.  His  procedure  was  to  arrange  the  pupils  of  a 
room  in  a  row  so  as  to  show  a  progressive  degree  of 
paleness.  Then  he  placed  by  themselves  all  those  whose 


MALNUTRITION  IN  SCHOOL  CHILDREN    103 

color  was  unsatisfactory,  and  rearranged  this  group 
according  to  thinness.  The  following  classes  are  then 
distinguished  and  in  the  proportions  named :  — 

TABLE  16 

1.  Excellent  in  all  respects 24.6  per  cent 

2.  Average 32.7 

3.  Average  nutrition  with  pallor 17.3 

4.  Deficient  nutrition  without  pallor 13. 

5.  Deficient  nutrition  with  pallor 12.3 

If  groups  4  and  5  are  thrown  together  and  group  3 
regarded  as  satisfactory,  we  have  a  total  of  25.3  per 
cent  ill-nourished. 

Fewer  studies  have  been  made  in  rural  schools.  Such 
evidence  as  is  available  indicates  that  the  proportion  of 
ill-nourished  is  somewhat  less  than  in  the  large  cities, 
but  that  it  is  very  great.  This  is  further  indicated  by 
the  fact  that  tuberculous  school  children  are  only  a 
little  less  numerous  in  country  than  in  city  schools.  Of 
course  there  are  exceptional  schools,  both  rural  and 
urban,  where  few  ill-nourished  children  are  to  be  found, 
but  the  teacher  of  forty  children  may  ordinarily  expect 
to  have  anywhere  from  two  or  three  to  eight  or  ten 
who  are  below  par  in  nutrition.  It  would  be  well  for 
her  to  try  to  identify  them  and  to  correlate  her  findings 
with  their  school  progress,  deportment,  nervous  con- 
trol, etc. 

The  above  statistics,  which  are  all  based  on  actual 
medical  examinations,  thus  show  that  from  6  to  30  per 
cent  of  the  school  children  suffer  from  malnutrition. 
The  average  would  seem  to  be  between  10  and  15  per 
cent,  at  least  for  cities,  throughout  western  Europe  and 


104    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

America.   The  number  is  largest  in  the  earlier  years 
and  decreases  gradually  in  the  upper  grades. 

Inadequate  feeding  as  a  cause  of  malnutrition 

Investigations  usually  show  that  from  10  to  15  per 
cent  of  those  living  in  the  poorer  districts  of  our  large 
cities  are  inadequately  fed.  Leckstrecker  found  that  of 
10,707  industrial  school  children  of  New  York  City, 
439  had  no  breakfast,  998  had  only  coffee  and  bread, 
and  only  17  per  cent  a  satisfactory  breakfast;  998 
were  ansemic.  Harrington  found  that  of  the  5043  ill- 
nourished  children  in  Boston,  33  per  cent  received  an 
"unsatisfactory"  breakfast.  Seventy  per  cent  of  Bos- 
ton's poorly  fed  came  from  homes  classed  as  well-to-do. 
Of  12,800  children  in  16  New  York  schools  who  were 
questioned  privately  by  the  principals,  7.7  per  cent 
had  no  breakfast,  and  15.3  per  cent  more  only  bread 
with  coffee,  tea,  beer,  etc.  A  similar  investigation  in 
Buffalo  returned  4.46  per  cent  as  breakfastless  and  9 
per  cent  more  as  having  had  entirely  too  little.  Mac- 
millan  states  that  at  least  5000  children  in  Chicago  are 
habitually  hungry. 

Bernhard  l  found  that  of  8451  school  children  of  Ber- 
lin, .5  per  cent  had  had  no  breakfast  and  6.8  per  cent 
almost  none.  In  Munich,  a  few  years  ago,  1557  break- 
fastless school  children  were  found.  Christiania,  Nor- 
way, had  over  3000  ill-nourished  school  children  in 
1901.  Of  these,  52  per  cent  had  no  breakfast,  the 
remainder  only  coffee  and  bread.  In  Pavia,  Italy, 
*  See  Kelynack's  Medical  Inspection  of  Schools,  p.  374. 


MALNUTRITION  IN  SCHOOL  CHILDREN    105 

January  17,  1900,  of  2500  children  in  four  schools,  10 
per  cent  had  come  to  school  without  breakfast  and  50 
per  cent  with  an  inadequate  one.  In  Padua,  the  same 
year,  over  5  per  cent  had  no  breakfast  and  nearly  50 
per  cent  one  that  was  unsatisfactory. 

Data  secured  by  Dr.  E.  B.  Hoag  from  3000  school 
children  in  the  smaller  cities  and  towns  of  Minnesota 
showed  that  65  per  cent  had  breakfast  with  no  proteid, 
85  per  cent  with  no  fruit,  and  60  per  cent  without 
either  a  fruit  or  a  proteid  food. 

If  the  breakfastless  child  invariably  received  a  satis- 
factory dinner  and  supper,  the  situation  would  not  be 
so  serious.  But  investigations  show  that  this  is  not  the 
case.  Among  families  which  are  either  poor,  ignorant, 
or  neglectful,  the  noon  meal  is  likely  to  be  even  worse 
than  the  breakfast.  In  one  group  of  New  York's  badly 
nourished  children,  68  per  cent  returned  at  noon  to 
homes  where  no  regular  noon  meal  was  prepared.  In 
two  schools  where  13.3  per  cent  of  the  children  were 
ill-nourished,  5  per  cent  of  all  the  mothers  worked  away 
from  home.  In  such  cases  the  pennies  which  are  given 
to  the  children  for  buying  lunches  are  usually  expended 
for  the  worst  imaginable  food, — cookies,  candy,  cream 
puffs,  cornucopias,  doughnuts,  third-grade  bananas, 
pickles,  etc.  The  more  extreme  and  chronic  the  insuffi- 
ciency of  nutrition,  the  more  perverted  the  appetite 
is  likely  to  be.  As  Spargo  has  remarked,  the  craving 
of  the  ill-nourished  child  for  pickles  and  other  unwhole' 
some  articles  of  food  is  analogous  to  that  of  the  alcoholic 
fiend  for  his  favorite  beverage.  Much  of  the  food  thus 


106    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

purchased  by  the  child  comes  from  street  venders  and 
other  questionable  sources,  and  is  likely  to  be  unclear 
as  well  as  unwholesome. 

We  must  regard  inadequate  feeding,  therefore,  as 
one  of  the  important  causes  of  malnutrition.  This  is 
due  sometimes  to  poverty,  but  more  often  to  ignorance 
and  neglect.  The  statistics  just  quoted  show  this  con- 
vincingly, though  it  is  of  course  impossible  to  separate 
the  influence  of  poverty,  ignorance,  neglect,  bad  hous- 
ing, deprivation  from  play,  sleep,  etc.  Regularity  of 
meals  and  care  in  the  selection  and  preparation  of  the 
child's  food  cannot  be  too  strongly  emphasized,  and 
in  such  matters  the  parents  in  comfortable  houses  are 
often  at  fault.  Children  pay  the  penalty  when  mothers 
have  not  been  rightly  educated.  The  malnutrition 
problem  is  therefore  about  one  third  economic  and  two 
thirds  educational.  Teacher  and  school  doctor  should 
not  hesitate  to  inform  well-to-do  mothers  when  their 
children  are  found  undernourished,  even  at  the  risk  of 
giving  offense. 

Other  causes  of  malnutrition 

In  the  case  of  no  other  common  defect  is  the  degree  of 
parental  care  so  great  an  influence.  Investigators  find, 
for  example,  that  malnutrition  is  far  less  common 
among  Jewish  than  among  Gentile  children,  even  when 
the  latter  are  at  an  economic  advantage.  Dr.  Hall's 
figures  show  Jewish  children  in  London  to  be  6 \  pounds 
heavier  and  2^  inches  taller  at  the  age  of  ten  than  other 
children  in  the  same  schools  (11,  p.  490).  The  mor- 


MALNUTRITION  IN  SCHOOL  CHILDREN    107 

tality  rate  for  Jewish  children  in  the  first  year  is  de- 
cidedly lower  in  every  country  than  that  for  children 
of  other  peoples.  The  difference  is  not  thought  to  be 
due  to  racial  heredity,  but  to  the  more  general  care 
given  to  infants  in  the  Jewish  home. 

Parental  neglect  and  ignorance  are  often  responsible 
for  underfeeding,  for  pampering  the  child  in  his  food 
habits,  and  for  the  use  of  stimulants  such  as  tea,  coffee, 
and  alcoholic  drinks.  The  same  cause  is  responsible  for 
insufficiency  of  sleep,  over-excitement,  and  many  other 
enervating  influences  which  affect  the  child's  ability  to 
digest  and  assimilate  its  food.  The  child  thrives  not  OD 
what  it  eats,  but  on  what  it  can  digest  and  assimilate. 

Insufficient  clothing  aggravates  malnutrition  by  rob- 
bing the  body  of  its  heat.  The  child  who  is  scantily 
fed  and  scantily  clothed  is  compelled  to  burn  his  candle 
at  both  ends.  For  many  a  pinchbeck  youngster,  boots 
and  a  warm  dinner  are  equally  necessary. 

The  overwrought,  nervous  child  is  nearly  always 
ill-nourished,  and  this  in  turn  aggravates  still  further 
the  nervous  instability.  Carious,  aching,  or  irregular 
teeth  and  diseased  gums  are  at  the  bottom  of  many 
cases  of  malnutrition.  Adenoids  and  enlarged  tonsils 
induce  a  condition  of  general  toxaemia  which  pro- 
foundly affects  nutrition.  Many  cases  are  traceable 
almost  entirely  to  eye  strain,  or  other  reflex  nervous 
disturbances,  such  as  those  produced  by  parasites,  etc. 
Worry  and  unhappiness  have  a  similar  effect.  Rollick- 
ing fun  and  happiness  are  essential  alike  for  correct 
physical  and  for  healthy  mental  growth. 


108    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

External  causes  seldom  act  alone.  There  are  chil- 
dren of  robust  constitution  whose  growth  momentum 
seems  to  defy  every  kind  of  unfavorable  environment. 
There  are  others  whose  growth  suffers  for  every  trifling 
cause.  These  are  the  children  whose  powers  of  diges- 
tion and  assimilation  are  feeble  by  native  endowment. 
"  Delicate  "  best  describes  them.  They  are  often  bright, 
nervous,  and  sensitive  to  every  influence.  The  com- 
bined efforts  of  education,  medicine,  and  home  training 
are  necessary  in  order  to  usher  such  children  into 
an  efficient  manhood  or  womanhood.  With  them  the 
strenuous  life  of  the  school  may  be  but  an  added  bur- 
den. Let  the  school  beware  that  it  cast  not  its  influ- 
ence with  the  afflictions  of  evil  heredity  and  stunting 
environment. 

The  assimilation  of  food  depends  not  only  on  the  food 
itself  and  the  soundness  of  the  digestive  apparatus,  but 
fully  as  much  upon  the  influences  exerted  on  metab- 
olism by  bodily  activity.  The  tissues  can  starve  for 
oxygen  in  the  out-of-doors  if  the  bodily  functions  are 
not  stimulated  by  exercise.  In  like  manner,  the  child 
who  hugs  his  books  for  six  or  more  hours  per  day  may 
suffer  malnutrition  in  the  midst  of  abundance.  There 
is  no  way  for  the  school  to  atone  for  the  evil  it  does 
when  for  a  dozen  years  it  assiduously  cultivates  perni- 
cious habits  of  sedentary  living. 

Identifying  the  ill-nourished 

The  worst  cases  of  malnutrition  can  be  identified 
easily  enough  by  any  one  whose  eye  has  been  trained 


MALNUTRITION  IN  SCHOOL  CHILDREN    109 

to  detect  unhealthy  skin  color,  thinness  of  the  body, 
undersize,  and  the  symptoms  of  lassitude.  But  in  the 
case  of  many  children  a  sure  diagnosis  is  not  gained  by 
casual  inspection.  In  a  field  where  even  the  experienced 
school  doctor  sometimes  falls  into  error,  the  teacher 
cannot  hope  to  avoid  all  mistakes.  It  is  believed,  how- 
ever, that  nothing  but  good  can  result  from  a  habit  of 
attention  to  the  symptoms  most  commonly  involved. 
In  malnutrition  the  face  is  not  usually  thin  and 
pinched,  but  often  plump  in  appearance,  and  for  this 
reason  many  cases  are  overlooked.  In  such  cases  the 
fat  lacks  firmness  and  is  not  healthy.  Often  there  is  a 
fullness  under  the  eyes.  The  color  is  usually,  but  not 
invariably,  pale.1  The  skin  is  likely  to  be  harsh  and 
inelastic,  the  hair  deficient  in  luster,  and  the  eyes  dull 
or  "nervous,"  with  pale-blue  rings  beneath.  The 
breath  may  be  foul,  with  other  symptoms  of  indiges- 
tion. Motor  symptoms  are  common,  especially  twitch- 
ings  of  the  eyelid  and  tongue,  unsteadiness  of  body 
balance  as  shown  by  Warner's  simple  tests;  and  in 
extreme  cases  movements  approaching  the  choreiform 
may  be  marked.  Stuttering  may  develop.  The  child 
usually  plays  less  actively  than  the  average,  fatigues 
easily,  and  sleeps  badly.  Nightmares,  groundless  fears, 
and  obsessions  are  common.  The  child  may  be  either 
apathetic  and  listless  or  else  abnormally  high-strung 
and  irritable.  Children  of  the  latter  type  are  easily 
worried  by  school  work  and  develop  finical  habits.  The 

1  The  examiner  must  remember,  too,  that  the  color  of  the  skin  is 
influenced  by  the  temperature  of  the  room,  previous  exercise,  racial 
heredity,  etc. 


110    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


appetite  is  nearly  always  diminished  and  is  likely  to 
become  freaky.  Queer  food  preferences  and  violent 
aversions  are  formed.  The  best  foods  are  likely  to  be 
just  the  ones  most  disliked.  If  the  parents  are  un- 
wisely indulgent,  the  child  becomes  spoiled. 

Growth  may  be  markedly  affected.  Height,  weight, 
and  chest  girth  are  below  par  in  a  large  majority  of 
cases.  Measurement  of  weight  alone  will  disclose  many 
cases  of  malnutrition,  as  Wimmenauer  has  shown,  but 
because  of  racial  and  family  differences,  this  test  is  too 
unreliable  to  use  as  the  sole  criterion  in  the  individual 
case.  Nevertheless,  if  a  large  number  of  children  be- 
longing to  a  fairly  homogeneous  race  are  weighed  and 
found  to  average  considerably  below  the  weight  norms 
for  that  race,  it  may  be  inferred  that  the  group  contains 
an  undue  proportion  of  undernourished  children;  also 
that  a  majority  of  those  falling  farthest  below  the 
norm  for  their  respective  ages  are  undernourished.  In 
the  experiment  already  referred  to,  Wimmenauer  class- 
hied  1942  school  children  according  to  external  symp- 
toms of  nutrition  and  then  compared  the  well-nour- 
ished and  the  ill-nourished  in  height  and  weight.  The 
following  table  shows  the  average  excess  in  height  and 
weight  of  the  well-nourished  group  over  the  poorly- 
nourished  group  for  the  ages  6  and  9 :  — 
TABLE  17 


Age 

Boys 

Girls 

Height 

Weight 

Height 

Weight 

6to    7 
9  to  10 

5.0  cm. 
6.2  cm. 

S.    kg. 
5.5kg. 

4.4  cm. 

8.0  cm. 

2.8  kg. 
6.3kg. 

MALNUTRITION  IN  SCHOOL  CHILDREN    111 

Other  common  growth  symptoms,  in  case  the  malnu- 
trition is  long-standing,  are  carious  teeth,  delayed  den- 
tition, scoliosis,  and  rickets.  Scoliosis  is  favored  both 
by  the  less  active  life  and  by  the  muscular  weakness. 
Rickets  is  indicated  by  knock-knees,  bow-legs,  pigeon- 
chest,  beaded  ribs,  enlarged  joints,  and  sometimes 
retarded  mental  development.  Rickets  is  not  strictly 
a  "bone  disease,"  but  a  special  form  of  malnutrition 
which  has  many  other  results  besides  that  of  weaken- 
ing the  resistance  of  the  bones.1 

It  is  easy  enough  to  pick  out  the  half -starved  horse  or 
pig  from  his  well-fed  companions,  but  in  the  case  of  the 
child,  clothes  and  tidiness  deceive.  If  the  skin  over  the 
ribs  is  smooth  and  well-filled  out  above  and  below 
the  nipples,  nutrition  is  probably  not  defective.  There 
should  be  no  marked  depressions  between  the  ribs. 
According  to  Wimmenauer  (42),  if  these  appear  be- 
neath the  nipples  only,  the  nutrition  may  be  considered 
"medium,"  but  if  there  are  deep  furrows  both  above 
and  below  the  nipples,  the  nutrition  is  "bad."  Wim- 
menauer also  suggests  that  measuring  by  means  of  cal- 
iper  compasses  the  thickness  of  a  fold  of  the  skin  held 
between  the  thumb  and  finger  gives  a  better  idea  of  the 
quality  of  the  adipose  tissue  than  can  be  gained  by 
mere  inspection. 

The  Oppenheimer  formula  for  the  determination  of 
nutrition  has  been  extensively  employed  with  school 
children  by  Schuyten.  According  to  this,  the  coeffi- 
cient of  nutrition  equals 

1  See  p.  79. 


112    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

girth  of  arms  X  100  1 
chest  girth 

The  condition  of  the  blood  is  a  valuable  index  of 
nutrition.  The  red  corpuscles  may  be  deficient  to  the 
extent  of  1,000,000  or  more  for  each  cubic  millimeter  of 
blood,  while  the  haemoglobin  content  may  run  as  low 
as  60  per  cent.  School  children  should  ordinarily  have 
a  corpuscle  count  of  about  4,500,000  per  cubic  milli- 
meter, and  a  haemoglobin  content  of  about  85  to  90 
per  cent.  Pre-tuberculous  children  entering  open-air 
schools  have  usually  a  haemoglobin  content  of  65  to 
75  per  cent.  This  is  the  reason  for  the  observed  palloi 
and  helps  to  explain  their  high  fatiguability  and  low 
power  of  resistance  to  disease. 

So  many  disorders  of  childhood  are  ushered  in  by 
anaemia  that  it  would  be  well  if  every  child  could  have 
two  or  three  blood  tests  during  his  school  life.  Anaemia 
is  especially  common  among  girls  in  the  earlier  years 
of  adolescence.  If  blood  counts  were  common  for  the 
high-school  girls,  teachers  might  consent  to  ease  some- 
what the  burden  of  work  for  a  year  or  two  in  the  case  of 
many  pupils.  For  the  anaemic  school  child,  boy  or  girl, 
there  is  no  cure  short  of  fundamental  reform  of  nutri- 
tion, and  this  is  possible  only  through  a  wisely  selected 
diet,  active  play,  sleep,  rest,  and  a  happy  life. 

Suggestions  for  identifying  the  ill-nourished  school  child 

The  teacher  cannot  hope  in  many  cases  to  make  the 
identification  certain.    The  following,  however,  are 
1  If  nutrition  is  normal  the  quotient  is  at  least  80. 


MALNUTRITION  IN  SCHOOL  CHILDREN    113 

some  of  the  common  indications  of  malnutrition.  The 
child  who  shows  several  of  the  symptoms  named  is 
likely  to  be  ill-nourished,  and  should  be  referred  to  a 
physician  for  examination. 

Is  there  pallor  of  skin? 

Is  the  child  extremely  thin? 

Are  there  furrows  between  the  ribs? 

_  the  arm  girth  (midway  between  elbow  and  shoulder)  X  100 

Does =30? 

chest  girth  (average  between  expiration  and  inspiration) 

Is  the  flesh  soft  and  flabby? 

Is  there  puffiness  under  the  eyes? 

Is  the  posture  slouchy? 

Does  the  child  appear  to  lack  physical  energy? 

Does  the  child  prefer  quiet  games  or  books  to  boisterous 
play? 

Is  the  child  listless? 

Is  mentality  slow? 

Is  the  appetite  freaky  (lack  of  appetite,  preference  for 
highly  seasoned  foods,  etc.)? 

Are  there  symptoms  of  nervousness? 

Does  the  child  have  frequent  headaches? 

Is  physical  endurance  good? 

Does  the  child  take  cold  easily? 

Is  there  shortness  of  breath? 

Is  sleep  disturbed? 

Are  there  indications  of  earlier  rickets  (bow-legs,  knock- 
knees,  pigeon-breast,  spinal  curvature,  badly  decayed 
teeth,  etc.)? 

Are  the  neck  glands  enlarged? 

The  responsibility  of  the  school 

The  first  duty  of  the  school  is  to  feed  its  hungry 

pupils.  The  oft-heard  argument  that  the  school  has  no 

concern  with  the  child,  except  to  educate  him,  is  now 

an  anachronism.  In  its  vocational  instruction,  play 


114    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

supervision,  moral  education,  health  examinations, 
and  medical  clinics  the  school  has  once  for  all  cut  loose 
from  its  moorings  to  the  "Three  R's."  The  school  is 
not  an  unchangeable  entity  whose  functions  are  prede- 
termined and  limited  by  definition.  It  is  fast  becoming 
the  recognized  agency  for  every  kind  of  child-welfare 
work,  and  the  most  effective  leverage  for  raising  the 
new  generation  to  a  higher  level  than  our  own.  As 
Robert  Hunter  reminds  us,  the  world  and  all  that  is  on 
it  will  soon  belong  to  the  children  now  in  our  schools, 
and  every  means  is  legitimate  which  can  help  to  make 
them  more  worthy  to  possess  it. 

Advocates  of  school  feeding  are  therefore  not  dis- 
turbed by  the  cry  of  "socialism."  It  is  no  more  social- 
istic than  free  education,  free  textbooks,  free  pencils, 
free  playgrounds,  and  medical  inspection.  It  is  no 
more  socialistic  to  heat  the  child's  body  internally  with 
food  than  to  heat  it  externally  by  warming  the  air  of 
the  schoolroom  (7). 

But  is  not  school  feeding  a  species  of  paternalism 
which  will  undermine  parental  responsibility?  Some 
people  are  obsessed  by  this  pauperization  argument. 
Parents  did  not  lose  interest  in  education  when  the 
State  assumed  control  of  it.  Health  supervision  in  the 
schools  does  not  make  parents  negligent  of  the  physical 
welfare  of  their  children.  On  the  other  hand,  the  more 
interest  the  State  displays  in  its  children,  the  more  the 
feeling  of  parental  responsibility  is  awakened. 

The  sad  truth  is  that,  too  often,  the  parents  of  neces- 
sitous children  have  little  parental  responsibility  to 


MALNUTRITION  IN  SCHOOL  CHILDREN    115 

destroy.  The  home  is  a  home  in  name  only.  The  inter- 
ference of  the  State  in  behalf  of  the  children  of  such 
parents  is  the  best  guaranty  that  the  parents  of  to- 
morrow will  be  different. 

Even  if  parents  were  pauperized,  school  feeding 
would  still  be  necessary.  Our  first  duty  is  to  the  chil- 
dren, not  to  the  parents.  "No  argument,  moral  or 
economic,  can  defeat  the  claims  of  a  hungry  child." 
"After  bread,  education,"  is  the  unanswerable  slogan 
of  the  Fabian  Society.  The  State  which  protects  chil- 
dren from  cruel  beating  will  sooner  or  later  protect 
them  also  from  slow  starvation. 

But  why  public  charity?  Cannot  private  philan- 
thropy cope  with  the  evil?  The  answer  is  that  it  is  not 
rightly  a  problem  for  charity  at  all,  any  more  than  is  ed- 
ucation itself.  Children  have  a  right  to  food,  and  when 
it  is  not  otherwise  forthcoming  the  State  has  the 
duty  to  supply  it.  If  private  charity  were  sufficient 
there  would  not  be  so  many  ill-nourished  children. 

Besides,  the  presence  of  such  children  in  the  school 
interferes  with  the  educative  process  itself.  Malnutri- 
tion makes  children  dull  and  retarded.  We  should 
not  expect  them  to  "  make  brick  without  straw."  To 
feed  them  is  both  less  expensive  and  more  effective 
than  to  educate  them  as  defectives  in  special  classes. 
The  school  has  the  right  to  protect  itself  against  the 
non-functioning  home. 

The  duty  of  the  school  is  so  much  the  clearer  for  the 
reason  that  it  is  itself  one  of  the  causes  of  disturbed 
nutrition.  It  imposes  upon  the  child  a  sedentary  life, 


116    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

instills  sedentary  habits,  confines  him  in  an  unhealth- 
f ul  atmosphere,  and  adds  the  burden  of  five  or  six  hours 
of  mental  work  which  often  entails  nervous  strain  and 
anxiety.1 

Finally,  it  should  not  be  overlooked  that  the  school 
meal  may  be  made  an  educational  influence  of  the  first 
rank.  It  offers  the  very  best  means  of  teaching  chil- 
dren neatness,  cleanliness,  and  good  manners.  The 
hygiene  of  foods,  the  "balance"  of  meals,  the  danger 
of  flies,  the  importance  of  thorough  mastication,  and 
the  care  of  the  teeth  cannot  be  so  effectively  taught  in 
any  other  setting.  The  work  of  preparing  the  meal 
offers  the  highest  type  of  training  in  social  cooperation. 
Some  of  the  ill-nourished  school  children  never  sit 
down  to  a  meal  in  the  "home."  Only  a  few  regularly 
use  a  tooth-brush  or  wash  the  hands  before  meals. 
Their  parents  often  have  no  conception  of  the  food 
requirements  of  children. 

And  these  parents  were  in  the  public  schools  a  few 
years  ago!  If  the  State  had  not  neglected  its  duty 
then,  it  would  have  smaller  responsibility  now  to  their 
neglected  children. 

The  best  argument  for  school  feeding  is  its  success 
where  tried.  For  many  years  most  of  the  cities  of  cen- 
tral and  western  Europe  have  served  free  meals  to 
their  necessitous  school  children.  Denmark  supplies 
by  public  taxation  free  lunches  to  one  third  of  the 
pupils  in  the  elementary  school;  Brussels  to  one  fifth, 
and  in  one  borough  to  all.  One  half  of  the  German 
1  Chapter  xxi. 


MALNUTRITION  IN  SCHOOL  CHILDREN    117 

cities  serve  either  breakfast  or  luncheon.  Munich 
began  the  work  over  a  century  ago,  and  now  continues 
the  free  meals  right  on  through  the  holidays.  Fifty 
cities  of  Italy  were  serving  free  meals  in  1910,  about 
one  half  of  the  expense  being  met  by  taxation.  Vercelli 
has  a  unique  and  praiseworthy  system,  making  attend- 
ance upon  the  free  meals  compulsory  for  all  the  chil- 
dren. Padua  has  served  free  school  breakfasts  since  1901 
to  the  number  of  about  one  half  million  annually  at 
a  cost  of  about  two  cents  each.  Tonzig  (41),  who  has 
studied  the  Padua  School  dietaries,  reports  that  for 
very  many  of  the  children  it  is  imperative  that  half  of 
the  day's  food  requirement  be  met  by  the  free  break- 
fast if  the  children  are  not  to  starve.  In  Italy  break- 
fast is  usually  preferred  to  luncheon.  Free  meals  are 
common  in  nearly  all  the  cities  of  Norway,  Sweden, 
Switzerland,  Spain,  France,  and  England.  London 
expends  over  $300,000  annually  in  this  way,  but  in 
London,  as  in  other  English  cities,  every  case  must  be 
passed  on  by  charity  organizations,  food  being  sup- 
plied free  only  in  cases  of  extreme  necessity.  The  usual 
criterion  of  necessity  is  a  family  income  of  less  than 
three  shillings  (seventy-five  cents)  per  child  per  week. 
Real  want,  of  course,  begins  well  above  this  point. 

The  most  advanced  country  in  the  treatment  of 
necessitous  school  children  is  France,  which  supplies 
free  meals  and  clothing  in  nearly  every  city.  Marseilles 
feeds  10  per  cent  of  her  school  enrollment.  Nice  serves 
free  luncheons  to  all  of  its  kindergarten  children  with- 
out distinction.  Nearly  all  of  the  recently  constructed 


118    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

school  buildings  in  the  towns  and  cities  of  France  are 
supplied  with  kitchens  as  a  matter  of  course.  The  Paris 
system  of  feeding  is  the  finest  in  the  world.  Lunches  are 
served  in  practically  every  school  and  are  patronized 
by  teachers  and  pupils,  rich  and  poor.  Children  who  can 
afford  to  pay  for  their  meals  are  expected  to  do  so,  but 
those  who  bring  no  money  are  given  their  meal  tickets 
without  question.  The  method  of  supplying  tickets  is 
such  that  no  child  knows  which  ones  of  his  fellows  get 
their  meals  without  payment.  One  third  of  the  chil- 
dren of  Paris  receive  free  lunches  by  this  system,  and 
one  thirtieth  of  the  total  school  expenditures  are  for  this 
purpose.  In  Paris,  after  a  third  of  a  century  of  experi- 
ment, the  tendency  is  to  enlarge  the  school  dietary  and 
to  exact  less  and  less  in  the  way  of  payment. 

America  is  behind  Europe,  but  is  making  rapid  prog- 
ress. Boston  first  served  free  meals  in  1894,  and  now 
supplies  them  in  several  schools  at  the  low  cost  of  two 
cents.  New  York,  which  began  in  1909,  has  a  School 
Luncheon  Committee,  under  whose  auspices  substan- 
tial school  meals  are  served  in  various  centers  at  the 
low  price  of  three  cents,  with  an  opportunity  for 
"penny  extras."  Chicago  undertook  the  work  on  a 
fairly  large  scale  in  1910,  and  at  the  present  time 
something  is  being  done  in  most  of  our  larger  cities. 
Although  the  beginning  is  most  promising,  probably, 
the  country  over,  not  more  than  one  ill-nourished  child 
out  of  a  hundred  is  receiving  the  full  attention  his 
case  merits.  With  us  the  school  lunch  is  seldom  free, 
and  ordinarily  receives  no  public  support  beyond  the 


MALNUTRITION  IN  SCHOOL  CHILDREN    119 

kitchen  equipment  and  supervision.  The  remaining 
expenses  are  met  by  the  fixed  charge  for  meals  and  by 
various  charity  organizations,  parents'  clubs,  private 
philanthropy,  etc. 

School  meals  should,  when  possible,  be  under  expert 
dietary  supervision  so  that  the  maximum  amount  of 
food  value  may  be  secured  for  a  given  outlay.  In  small 
schools  attended  by  older  children  it  is  often  feasible 
to  enlist  the  services  of  pupils  in  the  preparation  and 
serving  of  the  meal,  and  in  clearing  the  table,  washing 
dishes,  etc.  This  is  commendable  because  of  its  educa- 
tive value.  Experience  proves  that  when  the  cost  of 
raw  materials  alone  is  met  by  the  children  an  appetiz- 
ing and  nutritious  meal  may  be  served  for  about  three 
cents.  In  Philadelphia  one  cent  buys  about  one  hun- 
dred calories.  The  foods  most  in  evidence  are  sand- 
wiches, soup,  macaroni,  shredded  wheat,  rice  pudding, 
cereals,  potatoes,  hominy,  fruits,  milk,  cocoa,  etc.  It  is 
necessary  in  some  schools  to  take  account  of  racial  food 
preferences.  As  regards  expense,  until  the  time  comes 
when  the  school  lunch  takes  its  regular  place  as  a  part 
of  the  school  program,  as  free  as  tuition,  the  Paris 
method  of  meeting  the  cost  is  nearest  to  the  ideal. 

Nowhere  is  reform  more  urgent  than  in  the  lunch 
ceremony  of  the  rural  school.  Because  children  live  in 
the  country  is  no  reason  why  they  should  eat  with  dirty 
hands  and  piggish  manners.  As  Mrs.  Ellen  Richards 
suggests,  the  noon  hour  in  these  schools  could  very  well 
be  utilized  for  social  training  and  the  acquisition  of 
good  habits  and  refined  tastes.  Mrs.  Richards  (37) 


120    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

sketches  an  admirable  plan  for  the  rural-school  lunches, 
including  such  details  as  the  arrangement  of  the  table 
at  which  the  pupils  eat  the  lunches  they  have  brought 
from  home;  the  use  of  paper  napkins,  paraffin  paper  for 
plates,  and  a  kerosene  heater  for  preparing  some  spe- 
cial dish  to  supplement  the  individual  lunches.  The 
material  for  the  supplementary  dish  can  be  paid  for 
by  penny  or  two-cent  contributions  from  the  pupils. 
A  mothers'  organization  or  a  local  church  can  usually 
be  found  to  defray  such  shortages  as  may  arise  from 
the  inability  of  a  few  pupils  to  pay  their  share.  By 
varying  the  supplementary  dish  and  by  permitting  the 
older  children  to  aid  in  its  preparation  much  excellent 
instruction  in  cookery  can  be  worked  in.  Why  not 
a  toothbrush  drill  to  follow  the  meal? 

In  combating  malnutrition  two  other  important 
lines  of  influence  are  open  to  the  school.  Open-air 
schools,  with  their  shorter  study  program,  emphasis 
on  play  and  manual  work,  the  after-lunch  sleep  period, 
medical  supervision,  etc.,  are  no  less  important  than 
school  feeding.  The  two  methods  of  treatment  should 
go  hand  in  hand. 

Even  the  mere  contact  of  air  currents  with  the  body 
profoundly  influences  its  metabolism.  Experiments  of 
Rubner  (quoted  in  31)  prove  that  air  currents  too  mild 
to  be  perceptible  have  this  effect  from  passing  over  a 
small  exposed  surface  like  the  forearm.  The  sensation 
threshold  for  air  currents  is  about  one  hah*  meter  per 
second,  while  metabolic  changes  were  detected  for  air 


MALNUTRITION  IN  SCHOOL  CHILDREN    121 

currents  of  one  third  this  velocity.  The  effect  of  a 
thoroughgoing  outdoor  regimen  must  therefore  be  very 
great. 

Another  method  to  be  commended  is  that  of  under- 
taking systematic  instruction  of  parents  on  children's 
food  requirements.  This  method  has  been  used  by 
Poelschau  in  Charlottenburg  with  gratifying  results. 
Leaflets  were  prepared  setting  forth  in  simple,  untech- 
nical  language  the  importance  of  food  for  healthy 
growth,  and  giving  suggestions  on  such  subjects  as  food 
values,  balance  of  foods,  sample  dietaries  for  children 
of  different  ages,  the  injury  produced  by  alcohol,  tea, 
coffee,  abuse  of  sweets,  etc.  In  the  worst  cases  it  is 
advisable  for  school  nurses  to  visit  the  homes  and  give 
personal  assistance  and  advice.  The  food  leaflet  is  an 
easy  means  of  reaching  all  the  homes,  and  while  the 
advice  it  contains  will  often  fall  upon  stony  soil,  the 
amount  of  good  accomplished  is  probably  very  great  in 
comparison  to  the  time  and  expense  involved.  It  may 
be  sent  to  every  home  once  «iach  school  year,  and  in  the 
case  of  the  badly  malnourished  it  may  be  supplemented 
by  additional  leaflets  giving  more  detailed  suggestions. 

The  problem  of  malnutrition  is  one  which  presents 
numerous  aspects  and  varied  relations,  raising,  as  it 
does,  fundamental  questions  in  sociology,  economics, 
physiology,  and  hygiene.  The  problem  is  not  solved 
by  an  occasional  dole  of  food  in  or  out  of  the  school. 
What  is  demanded  is  a  constantly  adequate  diet,  better 
housing  and  clothes,  opportunity  for  play,  rest,  and 
sleep,  and  vigilant  medical  supervision  of  the  entire 


122    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

life.  With  the  possible  exception  of  housing,  the  school 
can  make  an  immense  contribution  along  all  these  lines, 
and  by  appropriate  education  in  household  science, 
hygiene,  and  related  matters  can  give  us  a  new  type  of 
parent  for  future  generations  of  children. 

Children's  dietaries 

For  extended  treatment  of  this  subject  the  reader  is 
referred  to  references;  as  6, 14,  20, 21, 23,  and  34,  at  the 
close  of  this  chapter.  It  is  a  subject  which  should  be 
taught  in  one  form  or  another  from  the  sixth  grade  to 
the  university.  Only  a  few  points  of  special  importance 
will  be  touched  upon  here. 

Children  need  much  more  food  than  adults  in  pro- 
portion to  size.  The  child  of  6  is  less  than  one  third  of 
the  adult  weight,  but  requires  one  hah*  as  much  food. 
Almost  as  much  food  is  required  for  the  child  of  12 
as  for  the  adult  engaged  in  moderate  labor.  If  diet 
is  insufficient  during  adolescence,  irreparable  harm  is 
likely  to  result.  Throughout  childhood  the  danger  is 
on  the  side  of  undereating  rather  than  overeating. 
When  children  are  given  the  appropriate  variety  of 
wholesome  foods  and  are  required  to  masticate  thor- 
oughly, the  matter  of  quantity  can  be  left  for  automatic 
adjustment. 

In  addition  to  repairing  the  daily  losses,  the  child 
must  grow,  and  it  is  therefore  hardly  to  be  supposed 
that  the  low  calories  allowance  favored  by  Chittenden 
for  adults  would  be  suitable  for  children  when  propor- 
tionately reduced.  It  has  not  even  been  proved  suffi- 


MALNUTRITION  IN  SCHOOL  CHILDREN    123 

cient  for  adults,  indefinitely  and  under  all  conditions. 
The  results  of  superabundant  feeding  in  open-air 
schools,  etc.,  would  seem  to  suggest  the  importance  of 
a  factor  of  safety  in  children's  diet.  In  order  to  provoke 
the  greatest  amount  of  food  assimilation  by  the  tissues 
it  is  probably  necessary  to  offer  them  a  little  more  than 
they  actually  need.  A  very  slight  deficiency  extended 
over  three  meals  a  day  for  365  days  in  the  year  may,  in 
the  long  run,  make  all  the  difference  between  a  well- 
nourished  and  a  poorly  nourished  child.  During  conva- 
lescence from  illness  the  problem  of  diet  becomes  doubly 
important. 

The  science  of  nutrition  involves  its  psychological 
as  well  as  physiological  and  chemical  factors.  A  theo- 
retically perfect  diet  may  work  poorly  in  practice  be- 
cause of  the  mental  attitude  it  calls  forth.  Food  that 
provokes  disgust  or  any  other  unpleasant  feeling  is 
badly  digested.  Food  preferences  and  aversions  some- 
times have  a  physiological  basis,  but  are  sometimes 
the  result  of  prejudice  and  bad  food  habits.  Bell  (4)  has 
shown  the  infinite  variety  of  these,  and  the  important 
part  played  by  them  in  determining  children's  diet. 
When  the  aversion  is  such  that  repeated  effort  on  the 
part  of  the  child  does  not  eradicate  it,  or  when  nausea 
and  vomiting  are  provoked,  it  is  best  to  omit  the  article 
of  food  altogether.  But  those  who  superintend  chil- 
dren's meals  should  take  every  opportunity  to  uproot 
such  aversions  and  injurious  preferences  as  are  founded 
purely  on  whim  and  habit. 

One  boy  known  to  the  writer  persistently  refused 


124    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

for  many  years  milk,  butter,  meat,  turnips,  carrots, 
green  beans,  lettuce,  celery,  parsnips,  beets,  cooked 
tomatoes,  and  cabbage.  Contracting  tuberculosis  at 
the  age  of  21  years,  he  was  led  to  consider  the  desira- 
bility of  overcoming  his  food  prejudices.  He,  therefore, 
set  about  the  matter  in  earnest,  with  the  result  that 
for  all  but  one  of  the  foods  (parsnips)  the  aversion  was 
readily  overcome,  almost  at  the  first  trial ! 

Bell's  investigation  of  the  food  preferences  and  aver- 
sions of  over  1400  children,  mostly  6  to  14  years  of 
age,  shows  that  few  children  escape  such  aversions  alto- 
gether and  that  very  many  contract  them  in  the  early 
years.  Some  of  the  aversions  seem  to  be  characteristic 
of  certain  well-defined  stages  of  growth.  The  school 
meal  offers  an  excellent  opportunity  for  the  education 
of  the  food  habits. 

REFERENCES 

1.  Dr.  A.  Albu:  "DerAntheil  der  Schule  an  den  Storungen  der 
Entwl.  u.  Ernahrung  der  Kinder."    Zt.  f.  Pad.  Psych.,  1908, 
pp.  243-53. 

2.  George  S.  Badger:  "Malnutrition  in  School  Children."  Proc.  of 
Cong.  Am.  Assoc.  Sch.  Hyg.,  1912,  pp.  186-89. 

8.  C.  H.  Bean:  "Starvation  and  Mental  Development."   Psych. 
Clinic,  1909,  pp.  78-85. 

4.  Sanford  Bell:  "An  Introductory  Study  of  the  Psychology  of 
Foods."   Fed.  Sem.,  1904.    (Especially  pp.  75-90.) 

5.  A.  A.  Boughton:  "Penny  Luncheons."  Psych.  Clinic,  1911,  pp. 
228-31. 

*6.  Louise  Stevens  Bryant:  School  Feeding.    1913,  pp.  345.    (The 

best  treatment  of  the  subject.) 
*7.  W.  H.  Burnham:  "Food  and  Feeding  of  School  Children." 

In  Monroe's  Encyclopedia  of  Education,  vol.  in,  pp.  627-30. 

8.  W.  B.  Cannon:   The  MecJianical  Factors  of  Digestion.  1911, 
pp.  227. 

9.  Charities  and  the  Commons:  Chicago's  Hungry  School  Children. 
October  17,  1908,  pp.  93-96. 


MALNUTRITION  IN  SCHOOL  CHILDREN    125 

10.  Sir  James  Chrichton-Browne:  Parsimony  in  Nutrition.    1909. 

pp.  111. 

*11.  W.  S.  Cornell:  The  Health  and  Medical  Inspection  of  Schools. 
1912,  pp.  479-504  and  599-603. 

12.  M.  E.  Derexia:  "Malnutrition  and  How  it  May  Show  Itself  in 
School  Children."    Trans.  III.  Soc.  for  Child  Study,  vol.  v,  pp. 
107-14. 

13.  Dock  and  Bass:  The  Hookworm  Disease.   1910,  pp.  250. 

*14.  Clement  Dukes:  The  Essentials  of  School  Diet.  London,  1899, 

pp.  211. 
15.  O.  H.  Dunbar:  "Three-Cent  Luncheons  for  School  Children." 

The  Outlook,  1911,  pp.  34-37. 
*16.  Dr.  Gastpar:  "Die  Beurteilung  des  Ernahrungszustandes  der 

Schulkinder."  Zt.  f.  Schulges.,  1908,  pp.  689-705. 

17.  Paul  le  Gendre :  "  Le  regime  alimentaire  des  enf ants  et  des  adoles- 
;         cents,"  etc.   Inter.  Mag.  Sch.  Hyg.,  vol.  iv,  1908,  pp.  202-16. 

18.  Sir  John  E.  Gorst:  The  Children  of  the  Nation.   (Chapter  v.) 

19.  J.  L.  Heffron:  "The  Diet  of  School  Children."   Jour,  of  Fed.. 
1900,  pp.  285-94. 

20.  Christine   Herrick:   "Food   Values   for   Children."    Harper's 
Bazar,  vol.  31,  pp.  160,  180,  282,  302,  384,  426,  450,  461. 

•81.  E.  B.  Hoag:  The  Health  Index  of  Children.  1911.   (Chapter  ix, 

"Foods  for  Children.") 

22.  E.  Holt:  Diseases  of  Infancy  and  Childhood.   1910,  pp.  230-37. 
*23.  Caroline  Hunt:  "The  Daily  Meals  of  School  Children."   Bull. 

U.S.  Bureau  of  Education,  1909,  pp.  62. 

f4.  Woods  Hutchinson:  "Dangers  of  Undereating."  Cosmopolitan 
Magazine,  August,  1909. 

25.  J.  Johnston:  Child  Wastage.  1908,  pp.  131.   (Chapter  vm.) 

26.  W.  H.  Jordan:  The  Principles  of  Human  Nutrition.  1912,  pp. 
450. 

*27.  Kaup  and  Rubner:  Die  Ernahrungsverhaltnisse  der  Volksschul- 

kinder.   Berlin,  1909,  pp.  170. 
28.  Helen  Kinne:  "School   Lunches."   Teachers    College    Record, 

1905,  pp.  90-106. 

*29.  John  Lambert:  "The  Feeding  of  School  Children."   In  Kely- 
nack's  Med.  Insp.  of  Schools  and  Scholars,  1910,  pp.  231-48. 

30.  C.  S.  Loch:  "The  Feeding  of  School  Children."   Yale  Rev.. 

1906,  pp.  230-50. 

31.  Graham  Lusk:  The  Science  of  Nutrition.  1909,402pp.   (Espe- 
cially chapters  vm,  x,  and  xi.) 

32.  W.  Leslie  Mackenzie:  The  Medical  Inspection  of  Schools.  1904. 
(See  contents.) 

33.  Mary  J.  Mayer:  "The  Vital  Question  of  School  Lunches." 
Review  of  Reviews,  1911,  pp.  455-59. 

*34.  Lucy  A.  Osborne:  "The  School  Luncheon."   Fed.  Sem.,  1912, 

pp.  204-19. 

35.  G.  Poekhau :  "  Die  Ernilhrung  der  Schuljugend  u.  ihre  Bekamp- 
fung  durch  Merkblatter,"  etc.  Zt.  f.  Schulges.,  1912,  pp  553- 
661. 


126    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

36.  George  Rainey:  "Necessitous  School  Children  in  London  and 
Paris."  School  Hygiene,  1912,  pp.  196-208. 

87.  Ellen  H.  Richards:  Good  Lunches  for  Rural  Schools  Without  a 
Kitchen.  Boston,  1906,  pp.  12. 

88.  Rowntree:  Poverty;  A  Study  of  Town  Life.   1905,  pp.  209^. 

89.  Dr.   M.   Schuyten:   "The  Nutrition  Coefficient  of  Antwerp 
School  Children."   School  Hygiene,  1913,  pp.  51-53. 

*40.  John  Spargo:  The  Bitter  Cry  of  the  Children.   1906,  pp.  337. 
*41.  Dr.   C.  Tonzig:   "Ueber  das  Schiilerfruhstiick,"  etc.    Zt.  f. 

Schulges.,  1904,  pp.  604-29. 
*48.  Dr.  Wimmenauer:  "Ueber  d.  Bestimmung  des  Ernahrungs- 

zustandes  bei  Schulkindern."  Zt.f.  Schulges.,  1912,  pp.  601-21. 
43.  Charles  E.  Woodruff:  "Nitrogen  Starvation."  North  American 

Review,  1910,  pp.  206-16. 


CHAPTER  IX 

TUBERCULOSIS  AND  THE  SCHOOL 

The  ravages  of  tuberculosis 

THE  annual  loss  of  lives  from  tuberculosis  in  the 
United  States  amounts  to  about  150,000.*  We  have 
constantly  one  half  million  people  ill  with  the  disease. 
About  two  million  others  are  kept  more  or  less  unhappy 
from  living  in  families  where  the  disease  is  present.  If 
the  death  rate  is  not  materially  reduced  within  the  next 
few  years,  five  million  of  the  present  population  of  the 
United  States  will  die  of  the  disease.  More  than  two 
million  children  now  attending  our  public  schools  will 
fall  victims  to  this  plague  unless  something  is  done  to 
save  them.  This  is  several  times  as  many  as  will  die 
from  smallpox,  diphtheria,  and  scarlet  fever  together. 

Unlike  most  diseases,  tuberculosis  strikes  down  the 
majority  of  its  victims  in  the  years  before  middle  age, 
when  society  has  already  met  the  cost  of  rearing  and 
educating  them  and  when  their  economic  productivity 
is  at  its  maximum.  On  an  average,  each  death  from 
tuberculosis  cuts  off  twenty-four  years  of  life,  seven- 
teen years  of  which  would  be  highly  productive.  The 
average  period  of  total  or  partial  disability  from  the 
disease  is  about  three  years.  The  annual  loss  in  wages, 

1  Probably  not  more  than  this  number  of  soldiers  were  killed  in 
battle  in  all  the  four  years  of  our  Civil  War. 


128    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

medical  attendance,  etc.,  amounts  to  more  than  one 
billion  dollars.  This  is  interest  on  a  capitalized  sum  of 
twenty- two  billions.  The  loss  is  equivalent  to  an  aver- 
age annual  tax  of  fifty  dollars  for  each  family  in  the 
United  States.  The  loss  each  year  is  almost  twice  as 
great  as  our  total  annual  expenditure  for  public  educa- 
tion and  more  than  twice  as  great  as  the  annual  cost 
of  our  army  and  navy. 

Most  of  this  loss  is  ultimately  preventable  and  prob- 
ably one  half  of  it  immediately  so.  Let  the  teacher  com- 
pute the  educational  harvest  that  could  be  reaped  by 
the  next  generation  if  only  one  half  the  yearly  cost  of 
tuberculosis  could  be  devoted  to  increasing  the  number 
of  teachers,  to  the  improvement  of  salaries,  to  the  es- 
tablishment of  vocational  high  schools,  continuation 
schools,  playgrounds,  health  supervision,  etc. 

By  what  means  and  through  what  agencies  may  this 
saving  be  effected?  One  thing  is  clear:  tuberculosis 
is  at  present  largely  a  social  and  educational  problem. 
Barring  the  possibility  of  some  medical  discovery 
which  would  eradicate  the  disease,  the  medical  profes- 
sion, unaided,  will  hardly  more  than  enable  us  to  main- 
tain the  slight  advantages  that  have  already  been 
gained.  Relatively  few  cases,  indeed,  come  under  the 
notice  of  a  physician  until  the  most  favorable  time  for 
effecting  a  cure  has  passed  by.  The  battle  cannot  be 
won  for  the  present  generation,  but  by  concentrating 
our  efforts  upon  children  it  may  be  won  for  the  next,, 
All  the  constructive  forces  of  society  should  be  organ- 
ized to  this  end. 


TUBERCULOSIS  AND  THE  SCHOOL   129 


Tuberculosis  in  childhood 

The  mortality  from  tuberculosis  among  adults,  after 
remaining  almost  stationary  for  at  least  a  century,  has 
decreased  about  50  per  cent  in  the  last  three  decades. 
Nearly  all  of  this  decrease  is  due  to  better  knowledge  of 
the  modes  of  its  dissemination  and  of  the  efficacy  of 
rest,  diet,  and  fresh  air  hi  its  treatment. 

But  statistics  show  convincingly  that  children  have 
not  shared  in  the  fruits  of  this  partial  victory.  Tuber- 
culosis kills  to-day  as  many  children  of  school  age  as  it 
did  fifty  years  ago.  This  is  made  clear  by  the  following 
table  from  Kirchner,  which  shows,  for  various  ages,  the 
average  annual  loss  of  life  in  Prussia  from  tuberculosis 
for  each  100,000  living:  — 

TABLE  18 


Average  for  females 

Age  in  ycjirs 

1876-1880 

1899-1903 

0-  1 

18.3 

16.5 

fl-5 

13. 

12. 

6-10 

3.2 

3.8 

10-15 

3.6 

3.7 

15-20 

8.7 

7.1 

20-25 

13.5 

10.8 

25-30 

19.2 

12.3 

80-40 

22.1 

12. 

40-50 

19. 

10. 

50-60 

16.5 

10.2 

60-70 

21.5 

11.4 

The  mortality  from  tuberculosis  below  the  age  of  20 
years  is  thus  seen  to  have  remained  practically  sta- 


180    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


tionaryfrom  1876  to  1903,  while  for  other  ages  the  same 
period  shows  a  remarkable  decrease. 

Phillips  (6,  p.  192)  presents  the  same  finding  for 
Scotland  and  concludes  that  the  school  plays  an  as- 
tounding part  in  increasing  the  liability  to  tuberculosis. 
His  figures  comparing  the  mortality  from  tuberculosis 
in  1905  with  that  in  1891  show  a  slight  increase  during 
this  period  for  the  ages  1  to  4,  a  decided  increase  from 
5  to  9  years  (8.75  per  cent),  and  a  very  great  increase 
from  9  to  14  (17.39  per  cent). 

The  extent  of  the  mortality  among  children  of 
school  age  from  tuberculosis,  as  compared  with  that 
from  so-called  "children's  diseases,"  is  far  greater  than 
is  usually  believed.  This  is  shown  for  ages  1  to  15  (for 
Prussia)  hi  the  following  valuable  table  from  Kirchner. 
The  table  shows  what  percentage  of  the  deaths  occur- 
ring at  any  particular  age  are  due  to  each  of  the  diseases 
listed. 

TABLE  19 


1 

fears 

0-1 

1-2 

2-8 

9-5 

6-10 

10-15 

Whooping-cough 
Measles  

3.8% 
1.45 

7.7% 
8.32 

5.85% 
7.63 

3.84% 
5.49 

1.46% 
2.87 

.18% 
.53 

Diphtheria  
Scarlet  fever.  .  .  . 
Tuberculosis.  .  .  . 

.62 
.32 
1.33 

4.44 

2.41 
4.32 

9.50 
7.98 
6.18 

14.51 
11.67 

8.73 

12.92 
13.37 
12.40 

4.29 
6.34 
30.03 

This  table  is  for  girls.  The  figures  for  boys  are  about 
the  same  except  that  the  percentage  from  5  to  10  years 
is  10.11  as  compared  with  12.4  for  girls;  and  from  10  to 


TUBERCULOSIS  AND  THE  SCHOOL    131 

15  years,  18.41  as  compared  with  30.03  for  girls.  An 
examination  of  the  table  shows  that  for  the  ages  5  to 
10,  tuberculosis  kills  about  as  many  children  as  scarlet 
fever  or  diphtheria,  and  more  than  three  times  as  many 
as  measles  and  whooping-cough  combined,  while  for 
the  ages  10  to  15  tuberculosis  kills  nearly  twice  as  many 
boys  and  three  times  as  many  girls  as  the  other  four 
diseases  combined. 

Whooping-cough  produces  its  highest  ratio  of  deaths 
from  1  to  2  years  and  takes  a  relatively  unimportant 
place  before  the  school  age  is  reached.  The  mortality 
from  measles  is  highest  from  1  to  3  years,  low  from  5  to 
10,  and  almost  negligible  from  10  to  15.  Diphtheria 
and  scarlet  fever  show  a  high  mortality  rate  from  2  to 
10,  when  a  rapid  decrease  begins.  Even  during  the 
years  of  school  life,  a  period  usually  thought  to  be  little 
productive  of  this  disease,  tuberculosis  is  a  more  fre- 
quent cause  of  death  than  any  of  the  so-called  "chil- 
dren's diseases." 

But  the  mortality  tables  do  not  inform  us  as  to  the. 
real  prevalence  of  tuberculosis  among  children.  It  is 
now  well  established  that  a  majority  of  children  con- 
tract tuberculosis  before  the  end  of  the  elementary- 
school  period.  This  was  first  revealed  by  autopsies  on 
the  bodies  of  deceased  children.1  In  1800  such  autop- 
sies Ganghofner  (6,  p.  325)  found  the  following  per- 
centages of  latent  tuberculosis:  — 

1  For  this  purpose,  of  course,  only  the  bodies  of  children  who  have 
died  of  other  causes  than  tuberculosis  are  used. 


132    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

TABLE  20 

460  cases  0-1  year  7.1  per  cent 

536  1-2  years  16. 

476  2-4  24.5 

271  4-6  26.9 

123  6-8  26.8 

Heubner,  Cornet,  Harbitz,  Comby,  and  Still  present 
similar  figures,  while  some  investigations  have  given 
even  a  higher  percentage. 

If  further  evidence  of  the  wide  prevalence  of  tuber- 
culosis among  children  is  desired,  it  can  be  gleaned  in 
convincing  abundance  from  the  results  of  tuberculin 
tests  made  upon  apparently  normal  children.1  Von 
Pirquet  applied  this  test  to  693  apparently  healthy 
children  and  found  a  positive  reaction,  increasing  from 
2  per  cent  in  the  first  year  to  35  per  cent  in  the  years  7 
to  10.  Hamburger  (quoted  in  7)  shows  that  Von  Pir- 
quet's  figures  are  much  too  low.  The  latter  secured  a 
positive  reaction  in  about  9  per  cent  at  2  years,  50  per 
cent  at  6  years,  and  95  percent  at  12  years.  Hamburger 
concludes  that  tuberculosis  is  a  true  children's  disease. 
"Just  as  everybody  goes  through  measles,  a  disease 
which  is  acquired  during  childhood,  so  we  can  say  that 
almost  every  one  acquires  tuberculosis  sometime,  and 
mostly  during  the  years  of  childhood."  By  the  same 

1  The  most  reliable  of  the  tuberculin  tests  is  the  one  devised  by 
Von  Pirquet,  which  is  made  by  scratching  the  skin  and  inoculating 
the  abrasion  with  a  small  amount  of  tuberculin  solution.  If  tuber- 
culosis is  present  an  inflammatory  reaction  occurs  at  the  point  of 
inoculation  within  twenty-four  hours.  While  this  tuberculin  test  of 
Vcn  Pirquet  is  not  thought  to  be  absolutely  infallible,  it  is  believed 
to  be  reliable  enough  to  give  approximately  correct  results  when 
used  with  large  numbers  of  individuals. 


TUBERCULOSIS  AND  THE  SCHOOL   133 

test  Jacob  (quoted  in  8)  found  a  positive  reaction  among 
43.9  per  cent  of  1927  German  school  children  examined; 
Tto,  of  Japan,  a  positive  reaction  from  43.9  per  cent  of 
£46  boys  and  from  50.5  per  cent  of  196  girls;  Herford 
(quoted  in  7)  a  positive  reaction  from  55  to  78  per  cent 
of  2594  English  children.  The  incidence  has  been  found 
to  be  about  as  great  in  the  country  as  in  the  city,  and 
to  be  very  high  among  the  children  of  the  best  classes. 

The  proportion  of  school  children  diagnosed  as 
tuberculous  is,  when  the  tuberculin  test  is  not  em- 
ployed, usually  very  much  less,  commonly  falling  be- 
tween 1  and  5  per  cent.  Thus  Dr.  Squire's  examination 
of  1670  non-selected  school  children  of  London  reports 
.47  per  cent  as  definitely  tuberculous  (pulmonary  tu- 
berculosis), .8  per  cent  as  doubtful,  and  2.8  per  cent  as 
having  morbid  chest  conditions  of  non-tubercular  char- 
acter. Fraenkel,  1906,  reports  1.26  per  cent  tubercu- 
lous among  17,236  school  children  examined  in  Berlin 
(1)  and  from  8.4  per  cent  (boys)  to  10.5  per  cent  (girls) 
as  predisposed  to  the  disease.  A  more  recent  investi- 
gation reports  1.61  per  cent  of  the  school  children  of 
Stockholm  as  infected  with  open  tuberculosis. 

In  the  United  States,  school  medical  examinations 
have  usually  been  too  superficial  to  disclose  any  ex- 
cept the  most  marked  cases,  and  to  quote  statistics 
from  such  examinations  would  be  misleading.  Euro- 
pean examinations  are  much  more  thorough.  Indeed, 
Grancher  (3),  of  Paris,  claims  to  have  demonstrated 
by  improved  methods  of  chest  diagnosis,  without  the 
use  of  tuberculin  tests,  the  presence  of  the  disease  in 


ouw/vr>jwrv 

134    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

from  14  to  17  per  cent  of  non-selected  school  children. 
All  the  school  children  in  an  average  district  of  Paris 
were  carefully  examined  by  him  and  his  assistants.  Of 
438  boys,  126  were  held  for  reexamination  as  suspects, 
and  of  the  latter,  62  (or  14  per  cent  of  all)  were  finally 
diagnosed  as  positively  tuberculous.  A  similar  proce- 
dure with  458  girls  gave  131  suspects  and  79  (17  per 
cent)  as  positively  tuberculous.  A  third  examination 
of  these  children  confirmed  every  diagnosis. 

These  figures  seem  high,  but  when  we  remember  that 
about  12  per  cent  of  our  school  children  later  actually 
succumb  to  the  disease,  and  that  very  many  others 
contract  it  in  a  severe  form  and  ultimately  recover,  it 
does  not  seem  an  exaggeration  to  say  that  at  least  15  or 
£0  per  cent  should  be  thought  of  as  definitely  predis- 
posed to  the  disease.  Kelynack  places  the  number  at 
25  per  cent. 

What  is  the  essential  significance  of  the  above  sta- 
tistics? It  would  perhaps  be  rash  to  infer  that  all  who 
contract  the  disease  are  in  very  serious  danger  of  dying 
from  it.  The  fact  that  by  far  the  larger  number  recover 
promptly  and  without  suspicious  symptoms  shows 
that  the  human  body  has  already  acquired  a  high  de- 
gree of  resistance.  A  large  minority,  however,  retain 
the  infection  in  latent  form,  and  often,  after  the  lapse  of 
many  years,  succumb  to  it.  It  is  now  believed  by  the 
best  authorities  that  many,  if  not  most,  tubercular  in- 
fections date  back  to  the  early  years  of  childhood.  The 
pulmonary  infection  which  first  becomes  evident  in 
adult  life  is  probably  not  usually  a  primary  infection, 


TUBERCULOSIS  AND  THE  SCHOOL   135 

but  a  continuation  of  infantile  tuberculosis.  Experi- 
ments with  animals  indicate  that  once  infected  an  ani- 
mal cannot  be  reinfected,  even  though  the  primary 
infection  remains  and  later  causes  death.  Hence,  since 
nearly  all  children  have  been  proved  to  be  harboring 
infection  before  the  years  of  adult  life,  those  who  first 
show  the  symptoms  of  the  disease  as  adults  are  in 
all  probability  victims  of  the  outbreak  of  an  old  and 
latent  infantile  infection. 

Dr.  Pollak  (quoted  in  4)  seems  to  have  proved  by  the 
study  of  case  histories  that  an  older  child  with  "mani- 
fest "symptoms  has  in  every  case  lived  in  close  personal 
contact  with  a  tuberculous  person  in  infancy,  most 
frequently  in  the  first  three  years  of  life.  It  is  also 
shown  that  the  earlier  in  infancy  the  primary  infection 
was  contracted,  the  less  favorable  are  the  chances  of 
recovery. 

The  disease  once  contracted  by  the  child,  there  are 
four  possibilities:  (1)  spontaneous  recovery  without 
manifest  symptoms  of  any  kind;  (2)  it  may  become 
manifest  and  lead  quickly  to  death;  (3)  after  becom- 
ing manifest  the  disease  may  disappear  after  more  or 
less  evident  illness;  or  (4)  there  may  be  a  relapse  after 
apparent  recovery.  Which  of  these  events  will  follow 
is  determined  both  by  the  native  vitality  of  the  indi- 
vidual and  by  the  circumstances  of  his  environment 
and  mode  of  life. 

The  seat  of  infection  in  children  of  school  age  is  less 
often  in  the  lungs  than  in  the  lymphatic  glands  or 
bones.  The  swollen  cervical  glands,  so  often  considered 


\ 


136    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

a  symptom  of  little  importance,  are  frequently,  if  not 
usually,  tuberculous.  Adenoids  and  enlarged  tonsils 
are  also  often  infected.  Of  905  adenoids  examined  by 
Dr.  Peters  (6,  p.  55),  45  per  cent  were  found  infected. 
Uicoll  found  10  per  cent. 

It  is  estimated  that  tuberculosis  of  the  bone  has 
made  cripples  of  at  least  150,000  people  in  the  United 
States.  This  form  of  the  disease  attacks  most  fre- 
quently the  spine,  hip,  or  knee.  Of  1000  cases  analyzed 
by  Young  (6,  p.  174),  416  involved  the  spine,  421  the 
hip,  and  103  the  knee.  It  is  tuberculosis  of  the  spine 
that  produces  the  deformity  known  as  hunchback, 
while  active  infection  of  the  hips  and  knee  are  familiar 
to  all  as  "hip-disease"  and  "white-swelling."  The 
most  frequent  onset  of  bone  tuberculosis  is  between  2 
and  9  years;  of  the  spinal  cases,  72  per  cent  begin  be- 
tween 1  and  5  years;  and  of  the  hip  cases,  64  per  cent 
between  2  and  6.  About  20  per  cent  of  the  bone  cases 
die  either  during  the  progress  of  the  disease  or  within 
a  few  years.  The  "expectation  of  life"  is  considerably 
below  normal  for  spinal  tuberculous  cripples  (6,  p. 
189). 

With  tuberculosis  of  the  bone,  as  with  the  pulmon- 
ary form  of  the  disease,  the  greatest  stress  should  be 
placed  upon  early  diagnosis.  When  treatment  is  begun 
early  enough,  recovery  is  almost  sure,  and  in  a  major- 
ity of  cases  without  resulting  deformity.  But  it  is  stated 
on  good  authority  (6,  p.  189)  that  in  95  cases  out  of  100 
of  spinal  tuberculosis  deformity  has  set  in  before  the 
diagnosis  has  been  made.  The  child  with  frequent  or 


TUBERCULOSIS  AND  THE  SCHOOL   137 

occasional  pains,  slight  rigidity,  or  tenderness  in  the 
joints  should  be  an  object  of  suspicion. 

As  regards  the  sources  of  contagion,  authorities  con- 
sider the  home  the  most  important.  Kirchner,  Gran- 
cher,  and  Walsh  have  followed  up  a  number  of  severe 
school  cases,  and  have  almost  invariably  found  tuber- 
culosis or  squalor,  or  both,  in  the  home  environment. 
Milk  may  be  an  occasional  source  of  infection  in  early 
infancy,  but  is  now  thought  to  be  responsible  for  rela- 
tively few  cases  among  older  children.  Only  a  few  can 
be  directly  of  school  origin  for  the  reason  that  tubercu- 
lous school  children  seldom  have  the  disease  in  the 
open  form  and  are  thus  not  sources  of  danger  to  their 
fellows.  Practically  the  only  school  danger  comes 
from  the  teacher  herself.  From  1  to  3  per  cent  of 
teachers  have  been  found  tuberculous.  There  are  prob- 
ably a  quarter  of  a  million  school  children  daily  exposed 
to  infection  from  this  source  in  the  United  States.1 

Means  of  prevention 

No  plan  of  campaign  against  tuberculosis  can  pos- 
sibly meet  success  which  does  not  center  its  main  efforts 
upon  infancy  and  childhood.  Since,  according  to  Ham- 
burger, the  pulmonary  tuberculosis  of  adults  is  only  the 
tertiary  form  of  a  primary  infection  which  occurred  in 
infancy,  and  of  which  the  gland  and  bone  infections  of 
school  children  are  the  secondary  form,  the  logical  and 
most  effective  method  would  be  to  prevent  the  infec- 
tion of  infants  by  removing  them  from  all  contact  with 

1  See  Lewis  M.  Terman:  The  Teacher's  Health.  1913,  pp.  138. 


o-vUU*  V-i  w-^MOw-c\ 
138    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

persons  who  are  tuberculous.  But  this  would  involve 
the  breaking-up  of  family  life  to  an  extent  which  pres 
ent  laws  do  not  permit  or  public  opinion  sanction. 
Something  can  be  done  by  providing  free  public  hos- 
pitals and  camps  in  which  the  tuberculous  patients 
among  the  poorly  housed  could  be  isolated.  Housing 
laws,  of  course,  accomplish  something  by  lessening  the 
chances  of  infection.  What  many  a  child  most  needs  to 
keep  him  well  is  room  to  live,  sunlight,  air,  and  the  op- 
portunity to  play.  Poverty  that  condemns  children  to  a 
life  of  squalor  and  to  insufficiency  of  nutrition  harbors 
and  protects  the  disease  against  the  most  determined 
assaults  of  the  hygienist  crusader;  and  there  is  yet  no 
formula  for  the  abolition  of  poverty.  The  protection  of 
children  from  tuberculosis  is  a  problem  whose  solution 
can  be  attained  only  by  the  wholesale  cooperation  of 
medicine,  politics,  statesmanship,  industrial  reform, 
and  education.  The  most  effective  of  these  is  education. 
Infection  with  tuberculosis  in  early  childhood  is  so 
common  even  among  the  more  fortunately  situated 
classes  that  probably  for  many  years  to  come  a  con- 
siderable proportion  of  children  will  have  contracted 
the  disease  before  the  beginning  of  school  life.  We  can- 
not place  our  main  reliance,  for  the  present,  upon  the 
prevention  of  the  primary  infection.  Instead  we  should 
go  on  the  assumption  that  when  the  child  enters  school 
he  has  probably  suffered  a  primary  infection.  We 
should  then  proceed  so  to  order  his  life,  by  means  of 
the  school,  that  the  secondary  form  of  the  disease  will 
be  forestalled.  If  we  fail  in  this,  we  should  concentrate 


A-XjLJL~4> 


[a 
TUBERCULOSIS  AND  THE  SCHOOL        139^U. 

our  efforts  to  bulwark  the  body  against  the  tertiary,  or  . 
"open,"  form  of  the  disease.  It  is  foolish  to  begin  our  . 


expensive  operations  with  the  third  and  last  act  of 
drama. 

What  the  school  can  accomplish 

%. 

The  school  offers  the  only  satisfactory  opportunity/QAAAu>xv 
for  an  early  diagnosis  of  the  tubercular  predisposition. 
The  utilization  of  this  opportunity  to  the  fullest  would  (ftJCA/j 
gives  us  an  enormous  strategic  advantage.  Unfortu- 
nately it  has  not  been  utilized.  Our  school  medical 
examinations  are  entirely  too  superficial  to  uncover 
anything  less  obvious  than  the  open  case  or  the  most 
extreme  predisposition.  The  work  of  Grancher  and  his 
pupils  shows  how  inadequate  and  misleading  is  the 
average  school  medical  report  which  returns  no  more 
than  1  per  cent  of  the  pupils  as  showing  symptoms  of 
tuberculosis. 

When  the  tuberculous  or  pre-tuberculous  child  has 
been  found,  the  leading  aim  of  the  school  thereafter 
should  be  to  fortify  his  body  against  the  disease. 
Everything  else  should  give  way  to  this.  Teaching  and 
instruction  should  thereafter  be  considered  entirely 
incidental  to  this  one  central  aim.  This  should  include 
provision  for  appropriate  nourishment  (to  be  supplied 
by  the  school  if  it  is  not  forthcoming  at  home),  open- 
air  schools,  rest  and  sleep,  abundance  of  outdoor  play, 
a  specially  adapted  program  of  instruction,  and  con- 
stant medical  oversight.  The  home  should  be  visited 
and  parental  cooperation  enlisted  in  every  possible  way. 
The  school  physician  should  make  frequent  reexamin- 


JV 

140    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

ations,  including  blood  tests,  and  should  keep  in  the 
closest  touch  with  the  teacher  and  school  nurse.  When 
vacation  comes  it  is  folly  to  dump  the  child  back  into 
his  hovel  or  cramped  tenement  "home."  Instead  he 
should  be  taken  to  the  country  or  be  given  the  privilege 
of  the  "vacation  colony." 

Assuming  that  the  tuberculous  child  has  been 
brought  safely  through  to  the  end  of  school  life,  one 
more  obligation  remains;  namely,  a  final  and  thorough 
physical  examination  followed  by  some  earnest  voca- 
tional advice  which  will  insure  the  choice  of  a  trade  or  a 
profession  least  dangerous  to  the  person  of  tubercular 
tendency.  The  child  should  be  given  a  card  on  which 
the  most  important  occupations  are  listed  in  the  order 
of  danger  from  tuberculosis.  The  cause  of  hygiene  and 
the  economic  welfare  of  the  country  could  both  be 
served  by  persuading  children  of  tubercular  tendency 
to  take  up  farm  lif e  in  preference  to  shop  or  office  work 
in  the  city.  Vocational  guidance  will  find  its  most 
scientific  basis  on  the  side  of  physical  diagnosis  and 
medical  advice. 

In  countless  other  ways  the  school  can  safeguard  the 
children  so  as  to  forestall  the  secondary  and  tertiary 
stages  of  the  disease.  To  accomplish  this  most  effec- 
tively the  following  measures  are  necessary :  — 

(1)  Adequate  instruction  of  children  in  the  main 
principles  of  personal  hygiene.  Instead  of  being  re- 
served for  incidental  treatment,  hygiene  should  be  con- 
sidered as  one  of  the  three  or  four  most  important  sub- 
jects of  the  course  of  study  from  the  kindergarten  to 


TUBERCULOSIS  AND  THE  SCHOOL   141  /a, 


the  university.    A  large  share  of  hygiene  instruction    ^**-*'d[ 
could  well  be  devoted  to  the  causes  and  prevention  of       jp       I 
tuberculosis,  since  the  instruction  most  effective  for 
this  purpose  will  be  either  directly  or  indirectly  appli 
able  to  the  prevention  of  other  diseases. 

As  Gulick  has  emphasized,  the  special  instruction  on 
a  topic  like  tuberculosis  should  not  be  crowded  into 
one  or  two  years  of  school  life.  Information  thus  hur- 
riedly acquired  is  not  assimilated  in  any  vital  way. 
The  subject  should  be  taken  up  year  after  year  from 
different  angles  and  by  methods  adapted  to  the  child's 
stage  of  development.  In  the  earlier  years  the  instruc- 
tion should  take  the  form  of  the  inculcation  of  habits 
and  ideals  of  cleanliness  which  are  inimical  to  the  dis- 
ease. At  this  stage  it  is  not  necessary,  or  even  desirable, 
to  impart  specific  information  regarding  the  nature  of 
tuberculosis,  nor  need  it  even  be  mentioned  by  name. 
By  the  third  or  fourth  grade,  more  specific  instruction 
should  begin  and  should  be  planned  so  that  each  year 
some  new  aspect  of  the  subject  is  made  thoroughly 
familiar  to  the  pupils.  In  one  grade  the  stress  could  be 
placed  upon  the  value  of  fresh  air  and  the  ordinary 
means  of  obtaining  a  maximum  amount  of  outdoor  life. 
In  another  grade  the  relation  of  tuberculosis  to  alcohol 
could  be  made  prominent.  At  another  time,  the  influ- 
ence of  fatigue,  ill-nourishment,  etc.,  and  still  later  the 
social  and  economic  aspects  of  the  problem.  Not  aU 
the  necessary  knowledge  of  the  related  physiology  and 
anatomy  can  be  assimilated  in  any  one  grade,  and 
accordingly  this  should  be  worked  in  piecemeal  as  the 


142    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

child's  ability  to  understand  it  develops.  Thus,  year 
after  year,  while  taking  care  to  avoid  the  inculcation 
of  an  unreasoning  fear,  the  instruction  can  be  driven 
home  and  the  child  made  to  appreciate  the  necessity  of 
so  ordering  his  life  as  to  insure  a  reasonable  security 
from  the  disease. 

(2)  In  order  to  pave  the  way  for  the  improved 
methods  of  teaching  hygiene  in  the  public  schools, 
another  reform  is  first  necessary.  The  teachers  them- 
selves will  have  to  receive  more  adequate  instruction. 
Here  the  cooperation  of  the  normal  school  is  neces- 
sary. Reform  should  logically  begin  at  the  top.  Mean- 
while, something  can  be  done  by  superintendents  and 
school  physicians  to  educate  the  rank  and  file  of  teach- 
ers-in-service along  this  and  other  lines  of  personal  and 
social  hygiene. 

(3)  The  course  of  study  and  program  of  instruction 
also  need  to  be  reformed  to  accord  better  with  the 
psychological  laws  pertaining  to  economic  methods  of 
learning,  fatigue,  the  hygienic  use  of  the  school  day, 
etc.  If  by  improved  methods  one  or  two  hours  per  day 
can  be  saved  from  instruction  hi  writing,  spelling, 
arithmetic,  etc.,  without  loss  to  the  child  in  those  sub- 
jects, hygiene  demands  that  part  or  all  of  the  time  thus 
gamed  be  devoted  to  other  activities  more  conducive 
to  health  than  the  usual  sedentary  occupations  of  the 
school.  The  latter  could  be  limited  to  two  hours  in  the 
lower  grades,  to  three  hours  in  the  middle  grades,  and 
to  four  hours  in  the  eighth  grade,  without  loss.  Play, 
rest,  manual  work,  gardening,  and  elementary  agricul- 


TUBERCULOSIS  AND  THE  SCHOOL   143 

ture  could  fill  up  the  remainder  of  the  school  day,  to 
the  child's  great  profit  both  physically  and  mentally. 
Overwork  of  the  predisposed  child,  in  school  or  out,  is 
a  potent  influence  transforming  a  latent  into  a  mani- 
fest infection.  When  animals  which  have  been  ex- 
perimentally inoculated  with  the  disease  are  compelled 
to  overwork  in  a  treadmill,  they  succumb  much  more 
quickly  than  those  which  are  not  so  treated. 

(4)  The  widespread  interest  in  playgrounds  should 
be  still  further  encouraged.    The  nation  has  not  yet 
one  tenth  enough.  In  the  city  the  employment  of  play- 
ground instructors  should  be  as  much  a  matter  of  course 
as  the  employment  of  the  classroom  teacher.  Normal 
schools  and  teachers'  colleges  have  here  one  of  their 
most  important  functions.    Every  outgoing  teacher 
should  have  had  some  instruction  in  the  psychology 
and  hygiene  of  play,  and  some  practical  experience  in 
the  supervision  of  children's  games.  The  special  play 
teachers,  of  course,  need  a  thorough  grounding  hi  all 
aspects  of  the  subject.    There  can  be  no  ideal  school 
without  its  spacious  playground  and  its  agricultural 
plot. 

(5)  Baths  should  be  installed  in  public  schools  and 
their  use  encouraged.    These  will  come  to  be  looked 
upon  as  more  necessary  in  proportion  as  play  and  other 
out-door  activities  are  introduced  into  the  school  day. 
School  baths  do  more  to  instill  habits  of  personal  clean- 
liness than  any  amount  of  didactic  instruction.   The 
shower  bath  should  be  regarded  as  one  of  the  necessi- 
ties in  school  architecture,  just  as  we  now  look  upon 


144    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

toilet  conveniences,  lavatories  for  the  hands  and  face, 
drinking-fountains,  etc. 

(6)  Seating  and  posture  must  receive  attention  ii 
the  lungs  are  to  be  normally  developed.   The  experi- 
ments of  Badaloni  are  here  in  point.1  Idle  lung  tissue 
must  be  reduced  to  a  minimum,  for  that  is  the  kind 
tuberculosis  prefers  to  nest  in. 

(7)  School  buildings,  until  we  can  contrive  to  get 
along  without  them,  should  be  better  ventilated  and 
should  be  kept  free  from  dust.   It  is  useless  to  expect 
the  linings  of  nose,  throat,  and  lungs  to  remain  healthy 
as  long  as  the  air  passages  are  kept  in  a  constant  state 
of   irritation   by   the  mineral   dust  of   the   average 
schoolroom.  Schoolrooms  can  be  kept  practically  free 
from  injurious  dust.2 

(8)  Since  tuberculosis  is  so  intimately  related  to  the 
alcohol  problem,  the  school  finds  here  an  additional 
motive  for  enlisting  in  the  cause  of  temperance. 

(9)  School  dental  and  medical  clinics  for  free  treat- 
ment are  an  indispensable  measure  in  the  fight  against 
tuberculosis.  Only  by  this  means  will  the  host  of  minor 
ailments,  so  important  in  the  prevention  of  tubercu- 
losis, be  given  the  appropriate  amount  of  attention, 
For  want  of  attention  to  the  minor  ills  many  children 
are  now  lost.  The  child  has  as  much  right  to  the  medi- 
cal treatment  which  will  make  his  health  and  educatior 
possible  as  he  has  to  the  education  itself.  The  amount 
of  medical  and  dental  treatment  received  by  children, 

1  See  page  397. 

*  See  Hoag  and  Terman:  Health  Work  in    the  Schools.     1914. 
(Chapter  on  "  School  Housekeeping.") 


TUBERCULOSIS  AND  THE  SCHOOL        145 

in  proportion  to  that  which  is  needed,  is  about  as  inade- 
quate as  their  education  would  be  if  there  were  no  pub- 
lic schools.  The  requirements  of  the  body  are  as  much 
a  matter  of  social  concern  as  the  needs  of  the  intellect. 
Neither  can  safely  be  left  to  private  initiative  and  to  the 
business  enterprise  of  quacks. 

(10)  As  already  stated,  probably  a  quarter-million 
children  could  be  protected  from  the  danger  of  con- 
tagion at  school  if  the  tuberculous  teacher  were  elimi- 
nated.   By  means  of  a  system  of  retiring  allowances 
this  could  be  done  without  injustice  to  any  teacher. 

(11)  In  view  of  the  very  much  greater  incidence  of 
tuberculosis  among  girls  than  among  boys  in  the  earlier 
years  of  adolescence,  it  seems  highly  desirable  that  the 
hygienic  regimen  of  the  adolescent  girl  be  improved. 
This  would  doubtless  necessitate  reforms  both  in  the 
school  and  in  the  home.   Special  attention  should  be 
given  to  the  health  instruction  of  girls,  not  only  for  their 
own  good,  but  also  because  as  teachers,  mothers,  and 
keepers  of  the  home,  they  will  always  and  inevitably 
play  a  leading  part  in  the  hygiene  of  the  succeeding 
generation. 

(12)  The  prevalence  of  malnutrition  has  been  treated 
in  chapter  VHI.  It  need  here  only  be  pointed  out  that 
our  tuberculous  patients  are  recruited  largely  from  the 
15  or  20  per  cent  who  as  children  presented  the  symp- 
toms of  malnutrition.  These  children  must  be  reached 
in  some  way,  and  it  is  doubtful  whether  there  is  any 
way  which  does  not  lead  through  the  school. 

(13)  It  has  been  shown  that  the  period  of  con  vales 


146    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

cence  from  an  attack  of  whooping-cough  or  measles  is 
often  marked  by  the  passage  of  a  primary  infection 
into  the  secondary  stage,  or  of  a  secondary  infection 
into  the  tertiary.  Hence  weakly  children  need  to  be 
watched  more  carefully  and  permitted  a  longer  period 
of  rest  than  is  customary  in  such  cases.  Teachers  and 
parents  should  have  special  instruction  on  this  point. 
It  is  impossible  to  forecast  every  detail  of  the  school's 
contribution  to  the  warfare  against  tuberculosis.  We 
must  emphasize,  however,  that  little  ground  will  be 
gained  .unless  all  social  agencies  cooperate  in  a  broad 
way  and  use  every  resource  at  their  command  to  safe- 
guard the  child.  Private  philanthropic  measures,  good 
as  far  as  they  go,  can  never  cope  with  the  problem  in 
any  effective  way.  Because  the  school  offers  the  chief 
means  of  access  to  children,  it  is  necessary  to  make  it 
the  main  battleground  in  the  conflict.1 

REFERENCES 

*1.  Dr.  Fraenkel:  "Tuberkulose  u.  Schule."  Zt.f.  Schulges.,  1906, 
pp.  389-409. 

*2.  Dr.  Granjux:  "La  tuberculose  a  1'ecole."  International  Arch,  of 
Sch.  Hyg.,  vol.  n,  pp.  334-50.   (Summary  of  contributions  pre- 
sented at  the  1905  International  Congress  for  the  Prevention  of 
Tuberculosis.) 
8.  Dr.  Grancher:  "Preservation  scolaire  centre  la  tuberculose." 

International  Arch,  of  Sch.  Hyg.,  vol.  i,  pp.  131-45. 
4.  Dr.  Franz  Hamburger:  "Tuberculosis  in  Childhood."    School 

Hygiene,  1912,  pp.  119-21. 

6.  Dr.  Emmett  Holt:  Diseases  of  Infancy  and  Childhood.    1909, 
pp.  1070-1106. 

*6.  Dr.  T.  N.  Kelynack  (editor):  Tuberculosis  in  Infancy  and 
Childhood.  1908,  pp.  376.  (Written  by  many  authors.  Very 
important.) 

1  See  Hoag  and  Terman's  Health  Work  in  the  Schools,  chapter  on 
"Open-air  Schools." 


TUBERCULOSIS  AND  THE  SCHOOL   147 

7.  Dr.  James  Kerr:  "The  Elementary  Schools  and  Tuberculosis." 

School  Hygiene,  1910,  pp.  14-20. 
*8.  Dr.  M.  Kirchner:  "Tuberkulose  u.  Schule."    Zt.  f.  Schulei, 

1912,  pp.  1-27.  (Beiheft  giving  proceedings  of  the  12th  German 

Congress  of  School  Hygiene.) 
*9.  Dr.  M.  Kirchner:  Die  Tuberkulose  in  der  Schule.  Berlin,  1909, 

pp.  16. 
10.  F.  Lorentz:  "Metodische  Atemiibungen  in  der  Schule  u.  ihr. 

Wert  f.  d.  Tuberkuloseverschiitzung."    Zt.  f.  Schulges.,  1912, 

pp.  793-800. 

*11.  Dr.  Arthur  Newsholme:  The  Cause  and  Prevention  of  Tubercu- 
losis. London,  1908. 

12.  Dr.  Arthur  Newsholme:  "The  School  in  Relation  to  Tubercu- 
losis." Proc.  Second  International  Cong,  of  Sch.  Hyg.,  1907,  pp. 
426-30. 

13.  Dr.  Nietner:  "Die  Bekampfung  der  Tuberkulose  unter  den 
Schulkindern."    International  Mag.  of  Sch.  Hyg.,  1912,  pp. 
460-76. 

14.  Dr.  Mario  Ragazzi:  "La  scuola  nella  porfilassi  della  tuberco- 
losi."   International  Mag.  of  Sch.  Hyg.,  vol.  iv,  pp.  339-73. 

*15.  Dr.  Wimmenauer:  "Ueber  Tuberkulinempfindungen  nach  v. 
Pirquet  bei  Schulkindern."  Zt.  f.  Schulges.,  1912,  pp.  245-62. 

16.  See  International  Mag.  of  Sch.  Hyg.,  1912,  pp.  309-30  for  sum- 
mary of  proceedings  of  the  1912  International  Congress  for  the 
Prevention  of  Tuberculosis   (especially  papers  of   Badaloni, 
Jacob,  D'Espine,  Mery,  and  Wileminsky). 

17.  See  Proceedings  of  Sixth  International  Congress  for  the  Prewar 
tion  of  Tuberculosis  (especially  vol.  vi). 


CHAPTER  X 

THE  PHYSIOLOGY  OF  VENTILATION 

""Shades  of  the  prison  house  begin  to  close  upon  the  growing  boy." 

AIR  is  food  as  truly  as  meat  or  bread.  We  feed  the 
stomach  at  most  but  three  or  four  times  a  day,  the 
lungs  about  fifteen  times  a  minute.  We  are  nice  and 
discriminating  about  the  food  which  we  offer  the  stom- 
ach, but  we  complacently  consume  lung  food  which  is 
clouded  with  dangerous  mineral  dust  or  filthy  with 
organic  matter  derived  from  the  skin,  teeth,  and  mu- 
cous membranes  of  other  persons.  To  a  sense  of  smell 
of  ordinary  delicacy  a  first  whiff  of  typical  schoolroom 
air  is  likely  to  be  found  nauseating  and  stifling,  like 
the  morning  air  of  an  unventilated  bedroom. 

The  immediate  effects  produced  by  ill-ventilation 
are  headache,  drowsiness,  lassitude,  faintness,  dizzi- 
ness, nervousness,  and  in  extreme  cases  even  death. 

After  the  battle  of  Austerlitz,  of  300  Austrian  pris- 
oners who  were  herded  in  a  small,  ill- ventilated  prison, 
260  were  killed  by  impure  air.  Inl848,  about  100  steer- 
age passengers  of  an  English  ship  were  locked  up  in  a 
room  18  by  11  feet,  without  ventilation.  When,  a  few 
hours  later,  an  exit  was  forced  amid  scenes  of  frenzy 
and  violence,  72  were  found  dead. 

The  indirect  and  remote  effects  of  chronic  exposure 
to  unsuitable  ah-  are  not  so  well  known  because  they 


M»JC_>V^V 

V 

'V'OvAkAA>fc 
THE  PHYSIOLOGY  OF  VENTILATION      149 

are  not  so  spectacular,  but  they  are  none  the  less  real. 
Bad  ventilation  is  a  factor  in  the  production  of  nearly  \ 
all  kinds  of  diseases  which  have  their  seat  in  the  respir-  \ 
atory  passages,    including    tuberculosis,  pneumonia,    I 
diphtheria,    colds,    laryngitis,   pharyngitis,   nasal   or 
bronchial  catarrh,  hypertrophied  tonsils,  and  adenoids. 
Imperfect  aeration  of  the  blood  causes  general  debility. 
This  means  lowered  resistance  to  fatigue,  to  disease, 
and  probably  also  to  temptation.  Neither  physical  nor 
moral  victories  go  to  the  anaemic. 

Red  blood  is  at  a  premium  everywhere:  in  the  pul- 
pit, in  the  judge's  chair  or  the  jury's  box,  hi  the  doc- 
tor's office,  at  the  superintendent's  desk,  hi  factory  or 
mine  or  battle.  It  protects  us  from  tuberculosis,  pneu- 
monia, influenza,  and  many  other  diseases,  or  enables 
us  to  win  in  the  fight  against  them  when  they  have 
secured  a  hold.  Hardly  a  disease  is  known  which  may  1 
not  be  more  or  less  favorably  influenced  by  the  open-  1 
air  treatment. 

What  is  the  secret  of  this?  In  order  to  answer  the 
question  it  will  be  necessary  to  consider  briefly  the 
physiological  aspects  of  the  ventilation  question. 

Our  ventilation  problems  have  been  turned  over  to 
the  mechanical  engineer,  but  he  has  not  solved  them 
and  cannot  solve  them  alone.  Ventilation  is  first  of  all 
a  physiological  problem^  only  secondarily  and  inci-V*^ 
dentally  one  of  mechanical  engineering.  The  real  ob- 
ject is  not  schoolroom  ventilation,  but  body  venti- 
lation. This  is  a  physiological  problem. 

The  ventilation  "expert"  has  assumed  that  indoor 


150    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

air  is  healthful  when  it  is  kept  at  a  given  uniform  tem- 
perature (about  72  degrees),  when  the  carbon-dioxide  is 
kept  below  three  parts  in  ten  thousand,  and  when  the 
exchange  of  air  is  effected  without  perceptible  drafts. 
There  are  ventilating  systems  on  the  market  which  ful- 
fill these  demands  and  which  are  often  spoken  of  as 
ideal.  But  there  is  no  scientific  evidence  that  a  school- 
room ventilated  in  this  way  is  more  healthful  than  one 
which  has  to  depend  entirely  upon  window  ventilation. 
On  the  contrary,  the  experimental  evidence  seems  to 
prove  that  no  system  of  mechanical  ventilation  has 
succeeded  in  making  indoor  air  healthful.  Recent 
physiological  researches  on  this  point  even  suggest 
the  conclusion  that  the  "ideal"  ventilation  above  de- 
scribed is,  in  its  ultimate  effects  upon  the  human  body, 
anything  but  ideal. 

The  physiology  of  respiration 

In  order  to  locate  the  engineer's  fallacy  it  is  neces- 
sary to  review  some  elementary  facts  pertaining  to 
the  physiology  of  respiration. 

(1)  All  life  processes  involve  an  interchange  of  gases. 
In  one-celled  animals  this  interchange  occurs  directly 
through  the  cell  walls.  This  is  not  possible  for  all  the 
cells  of  the  human  body,  because  most  of  them  are  too 
far  removed  from  the  source  of  supplies.  Oxygen  must 
be  carried  to  them  and  gaseous  wastes  must- be  sewered 
away.  Therefore  we  are  furnished  with  lungs  and 
the  blood,  which  work  together  for  the  aeration  of 
the  farthermost  living  cell,  the  one  by  furnishing  the 


«  V  "i        \) 

THE  PHYSIOLOGY  OF  VENTILATION      151 

means  of  intake  and  outlet,  the  other  by  serving  as  the 
agent  of  distribution  and  elimination. 

The  lungs,  with  their  millions  of  air  cells  (variously 
estimated  at  from  4,000,000  to  700,000,000),  afford, 
when  extended  by  inspiration,  not  far  from  1350  squar* 
feet  of  surface  available  for  the  absorption  and  elimi- 
nation of  gases.  The  oxygen  is  combined  with  the  red 
corpuscles  of  the  blood  and  carried  to  every  part  of  the 
body.  In  similar  manner  the  blood  transports  carbon- 
dioxide  and  other  wastes  from  every  living  cell  to  the 
lungs  and  there  rids  the  body  of  them. 

(2)  This  interchange  of  gases  is  by  no  means  a  local 
problem  for  the  lungs  alone.    The  lungs  may  be  fully 
developed  and  healthy,  but  if  the  blood  be  deficient  in 
haemoglobin  (the  oxygen-carrying  element  of  the  red 
corpuscles),  the  cells  of  the  body  gradually  suffocate, 
just  as  the  inhabitants  of  a  city  would  famish  if  the 
distributing  mains  from  the  only  available  water-sup- 
ply were  to  become  permanently  clogged.  An  army's 
commissary  may  be  ever  so  well  filled,  but  if  its  com- 
munication with  the  army  is  blocked,  the  army  cannot 
live  and  fight. 

(3)  Good  lungs  and  pure  air  are  further  supple- 
mented by  the  action  of  the  heart.    We  breathe  as 
much  with  the  heart  as  with  the  lungs.  With  a  strong 
heart  and  plenty  of  healthy  oxygen-carriers  in  the 
blood,  a  person  need  not  be  concerned  about  the  size 
of  his  lungs.    Other  conditions  being  favorable,  the 
lungs  are  nearly  always  large  enough  to  accomplish 
their  work;  and  however  large  they  may  be,  their  effi- 


TGIENE  OF  THE  SCHOOL  CHILD 

ciency  is  strictly  dependent  upon  the  freight  capacity 
of  the  circulatory  system.  Large  lung  capacity  does 
not  give  increased  resistance  to  tuberculosis.  The  dan- 
ger lies,  not  in  lungs  which  are  naturally  small,  but 
in  unused  lung  tissue. 

(4)  But  heart,  blood,  and  lungs  together  cannot 
force  oxygen  upon  tissues  that  are  not  oxygen-hungry. 
Proverbially  you  can  lead  the  horse  to  the  trough,  but 
you  cannot  make  him  drink.  In  increasing  the  hunger 
of  the  tissues  for  oxygen,  nothing  else  is  as  effective 
as  muscular  activity.   The  active  sparrow  throws  off 
ten  times  as  much  carbon-dioxide  in  proportion  to 
body  weight  as  the  sluggish  toad,  the  boy  of  10  years 
40  per  cent  more  than  the  girl  of  the  same  age,  the 
youth  of  19  years  20  per  cent  more  than  the  old  man  of 
60.  We  produce  50  per  cent  more  carbon-dioxide  while 
walking  slowly  than  while  at  rest,  and  nearly  fifteen 
times  as  much  while  laboring  in  a  treadmill  as  when 
asleep.    Changing  the  rate  of  ordinary  walking  from 
two  miles  to  three  per  hour  increases  the  production  of 
carbon-dioxide  nearly  50  per  cent.    In  the  person  of 
sluggish  habits  metabolism  languishes.  One  who  never 
exercises  actively  is  literally  only  half  alive.    A  per- 
fectly ventilated  schoolroom  is  of  little  avail  for  chil- 
dren who  are  held  to  sedentary  book  work  for  six  or 
seven  hours  a  day. 

(5)  Breathing  itself  is  active,  not  passive.   The  air 
does  not  rush  into  the  lungs  and  expand  them,  but  the 
muscles  concerned  in  breathing  must  exert  themselves 
at  each  inspiration  to  enlarge  the  thoracic  cavity.   If 


—  ~\   i"  ••  fwwy  v\*v\ 

"to  j-va. 


THE  PHYSIOLOGY  OF  VENTILATION      153 

these  muscles  are  not  amply  nourished  and  kept  in  trim 
by  occasional  exercise  of  more  than  average  severity, 
they  grow  weak  and  lose  in  scope  of  movement.  This 
means  superficial  breathing,  a  disproportionate  amount 
of  idle  lung  tissue,  blood  insufficiently  aerated,  and 
general  weakness.  Again  we  see  that  body  ventilation 
is  impossible  in  a  life  of  inactivity. 

(6)  The  air  in  the  innermost  Jung  cells,  where  the 
interchange  of  oxygen  and  carbon-dioxide  takes  place, 
is  never  purified  directly.  The  lungs  are  not  emptied 
and  filled  at  each  expiration  and  inspiration.  If  the 
lung  capacity  is  3500  cc.,  the  "tidal  air,"  or  that  which 
is  expelled  at  each  expiration,  amounts  to  about  500  cc. 
(one  seventh).  Of  the  remainder,  about  one  half,  or 
1500  cc.,  can  be  expelled  with  special  effort.  This  is 
"reserve  air."  The  other  1500  cc.,  the  "residual  air," 
remains  absolutely  stationary  against  the  alveolar 
membranes.  From  it  the  blood  gets  its  new  supply  of 
oxygen  and  into  it  discharges  its  excess  of  carbon- 
dioxide.  The  residual  air  is  therefore  always  extremely 
impure.  Compared  with  tidal  air,  it  is  always  deficient 
in  oxygen  and  foul  with  waste  products.  The  residual 
air  cannot  possibly  be  purified  by  a  few  deep  breaths 
of  fresh  air.  Still  less  can  we  aerate  the  whole  body  hi 
this  way.  Ten  minutes  spent  in  breathing  exercises 
before  an  open  window  may  do  the  muscles  of  the  tho- 
rax a  little  good  and  act  as  a  wholesome  moral  tonic, 
but  this  is  not  a  substitute  for  a  day  of  normal  activity 
in  the  open  air.  As  well  might  the  long-distance  runner 
substitute  finger  exercises  for  his  training.  Vigorous 


7 


154    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

bodily  activity  impels  the  rapid  production  of  red  cor- 
puscles and  the  formation  of  haemoglobin.  We  breathe 
with  the  whole  body  (especially  with  the  muscles), 
not  simply  with  the  upper  one  seventh  of  the  lungs. 

(7)  Except  hi  extreme  cases,  the  healthfulness  of 
indoor  air  is  not  influenced  by  the  changes  which  occur 
hi  its  chemical  composition.    The  worst  ventilated 
schoolroom  is  never  deficient  enough  hi  oxygen  for  this, 
in  itself,  to  constitute  the  slightest  menace  to  health. 
Always  more  oxygen  is  available  than  is  necessary. 
Nor  is  carbon-dioxide  the  criminal  it  was  once  believed 
to  be.  There  is  never  enough  of  it,  even  in  an  under- 
ground bakery,  to  produce  any  discoverable  effects. 
The  normal  amount  in  the  atmosphere  is  .03  per  cent, 
and  the  proportion  never  goes  beyond  .4  per  cent  in  the 
worst  ventilated  schoolroom.    But  experiments  prove 
conclusively  that  it  requires  about  ten  times  the  latter 
amount  to  produce  any  noticeable  effect,  so  long  as  the 
air  is  normal  in  other  respects. 

As  already  indicated,  the  air  which  we  really  breathe 
is  not  the  air  in  the  room,  but  the  "residual  air"  which 
lies  next  to  the  alveolar  membranes  of  the  lungs.  But 
the  residual  air  always  contains  5  to  6  per  cent  of  car- 
bon-dioxide, regardless  of  the  degree  of  purity  of  the  air 
which  is  inhaled.  It  is  evident,  therefore,  that  carbon- 
dioxide  cannot  be  guilty  of  the  crimes  which  have  been 
charged  against  it. 

(8)  The  more  recent  theory,   that  the   injurious 
effects  of  bad  ventilation  were  due  to  the  presence  of 
organic  poisons  hi  expired  air,  has,  in  all  probability, 


THE  PHYSIOLOGY  OF  VENTILATION      155 

«io  more  foundation  than  the  carbon-dioxide  theory. 
The  experimental  results  of  Brown-Sequard  and 
d'Arsonval,  which  were  thought  to  prove  the  toxicity 
of  expired  air,  are  now  known  to  have  been  due  to 
imperfect  experimental  procedure.  While  the  air  of 
occupied  rooms  may  contain  organic  poisons  in  minute 
quantities,  the  numerous  experimental  studies  which 
have  been  directed  upon  the  problem  do  not  justify 
us  in  believing  that  under  any  ordinary  conditions 
these  are  great  enough  in  amount  to  produce  any 
injury. 

Another  theory  was  that  the  evil  effects  experienced 
from  breathing  the  air  of  crowded  rooms  result  from 
the  reflex  influences  produced  by  odors,  which  were 
thought  to  induce  changes  in  respiration,  circulation, 
heat  production,  and  nutrition.  This  theory,  also,  is 
rejected  by  the  best  authorities. 

Every  one  knows,  however,  that  confinement  in  ill- 
ventilated  rooms  is  unhealthful.  What  is  the  source  of 
the  injury? 

Air  currents,  temperature,  and  humidity 

These  are  now  believed  to  be  the  important  factors 
in  ventilation;  not  air  poisons  or  excess  of  carbon- 
dioxide.  They  produce  their  effects  chiefly  through 
their  influence  on  the  heat-regulating  mechanism.  It  is 
impossible  to  understand  the  principles  of  good  venti- 
lation without  consideration  of  the  body's  thermal 
phenomena. 

Whatever  the  temperature  of  the  air  around  us,  our 


.  c 

156    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

bodies  must  maintain  a  temperature  which  is  approxi- 
mately uniform.  Heat  loss  and  heat  gain  must  exactly 
balance. 


The  heat  of  the  body  is  produced  in  the  same  way  a& 
the  heat  of  the  furnace  or  stove,  i.e.,  by  oxidation.  Our 
food  is  our  heat  fuel.  When  the  body  is  too  rapidly 
cooled,  heat  production  is  hastened  by  increased  oxida- 
tion. This  acceleration  is  most  readily  brought  about 
by  an  increase  of  muscular  activity.  In  cold  weather 
our  muscles  "tone  up"  in  a  condition  of  partial  con- 
traction, and  at  the  same  time  the  circulation  be- 
comes more  vigorous.  In  hot  weather,  when  the  danger 
is  on  the  side  of  too  great  heat  production,  our  muscles 
relax  and  we  become  languid. 

But  the  body's  thermal  balance  could  not  be  kept 
up  merely  by  alterations  in  the  rapidity  of  heat  pro- 
duction. Means  are  provided  also  for  correspond- 
ing changes  in  the  rapidity  of  heat  loss. 

The  body  loses  heat  in  three  separate  but  mutually 
supplementary  ways;  by  radiation,  by  conduction,  and 
by  the  evaporation  of  sweat.  The  amount  lost  by  radi- 
ation depends  upon  the  temperature  of  the  surround- 
ing air,  upon  the  clothing  worn,  and  upon  the  amount 
of  blood  in  the  vessels  near  the  surface.  The  amount 
lost  by  conduction  depends  upon  all  these  factors  and 
in  addition  upon  the  humidity  and  movements  of  the 
surrounding  air.  The  amount  lost  by  evaporation  de- 
pends upon  a  number  of  factors,  relative  humidity  and 
air  currents  being  among  the  most  important. 

To  recapitulate,  the  heat  of  the  body  is  kept  uniform 


THE  PHYSIOLOGY  OF  VENTILATION      157 

by  a  marvelously  delicate  system  of  balances  involving 
the  following  mechanisms:  (1)  Means  for  increasing  or 
decreasing  the  rate  of  heat  production,  and  (2)  means 
for  regulating  the  rate  of  heat  loss.  The  latter  is 
accomplished  chiefly  in  two  ways;  (a)  by  regulation  of 
the  amount  of  blood  carried  to  the  skin,  and  (6)  by 
regulation  of  the  activity  of  the  sweat  glands. 

Which  of  the  above  means  will  be  brought  most 
effectively  into  play  in  any  given  case  will  depend 
entirely  on  the  special  conditions.  If  the  air  is  cold  and 
damp,  the  body  tends  to  lose  heat  too  rapidly  by 
radiation  and  conduction.  Accordingly,  the  blood  is 
driven  inward  by  vasomotor  constriction  of  the  blood 
vessels  of  the  skin,  and  both  conduction  and  radiation 
decrease.  The  sweat  glands  also  cease  their  activity 
so  as  to  prevent  still  further  loss  of  heat  by  evapora- 
tion. At  the  same  time  the  muscles  tend  to  partial 
contraction  so  as  to  increase  heat  production. 

On  the  other  hand,  when  heat  is  accumulating  too 
rapidly,  whether  because  of  vigorous  activity  or  exces- 
sively high  atmospheric  temperature,  vasomotor  con- 
trol fills  the  skin  with  blood  so  as  to  increase  radiation 
and  conduction,  and  the  sweat  glands  simultaneously 
hasten  their  work.  If  the  air  is  as  warm  as  the  body, 
no  heat  can  be  disposed  of  by  radiation  or  conduction, 
and  perspiration  becomes  our  sole  defense  against 
overheating.  If  the  air  is  excessively  humid  or  still, 
even  this  defense  is  destroyed  and  heat  apoplexy  may 
result. 

Any  condition  which  interferes  with  the  working  of 


158    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

this  complex  thermal  mechanism  is  likely  to  produce 
injury.  The  disturbances  which  actually  occur  are  of 
two  kinds:  external  and  internal.  The  external  include 
chiefly  such  factors  as  unsuitable  temperature  or 
humidity,  and  the  absence  of  air  currents.  The  inter- 
nal disturbances  include  unsuitable  activity  of  the 
sweat  glands,  of  the  heat-producing  mechanism,  and 
derangement  of  the  vasomotor  reflexes  which  regulate 
the  supply  of  blood  sent  to  the  skin. 

Of  the  external  influences,  temperature  and  humid- 
ity are  the  most  important.  Their  physiological  effects 
are  best  demonstrated  by  means  of  air-tight  cabinets 
such  as  those  used  by  Paul,  Brown-Sequard,  and  Hill. 
One  or  more  persons  are  inclosed  in  the  cabinet,  and 
the  effects  of  various  conditions  of  humidity,  tempera- 
ture, and  air  movement  upon  the  inmates  are  noted. 

Dr.  Paul  found  that  when  the  temperature  of  the 
cabinet  was  kept  at  sixty  degrees,  the  experimenter 
could  stay  in  the  cage  four  and  a  half  hours  without 
noticeable  symptoms,  although  long  before  the  close  of 
the  experiment  the  carbon-dioxide  content  of  the  air  in 
the  cabinet  was  far  higher,  and  the  oxygen  content  far 
lower,  than  is  ever  the  case  with  the  worst  ventilated 
schoolroom.  But  at  seventy-two  degrees,  only  a  few 
minutes  were  required  to  produce  feelings  of  mental 
dullness,  headache,  vertigo,  and  faintness.  Before  long 
the  body  temperature  rose  three  degrees.  Then  an 
electric  fan  was  started  and  the  symptoms  almost 
immediately  vanished. 

Hill's  experiments  with  air-tight  cabinets  proved  that 


THE  PHYSIOLOGY  OF  VENTILATION      159 

when  the  air  was  kept  cool  and  in  motion  the  subjects 
suffered  no  ill  effects  even  when  the  proportion  of 
carbon-dioxide  was  twenty  times  as  great  as  it  ever 
is  in  badly  ventilated  houses.  At  this  point,  the  oxy- 
gen content  was  so  low  that  candles  would  not  burn 
and  the  inmates  could  not  light  their  cigarettes  with 
matches.  When  the  temperature  of  the  air  was  sud- 
denly increased  by  means  of  an  electric  stove,  the 
usual  symptoms  of  rapid  heart-beat,  increased  body 
temperature,  and  feelings  of  distress  quickly  made 
their  appearance.  Electric  fans  were  then  started  and 
the  passage  of  swift  air  currents  over  the  body  brought 
almost  instant  relief. 

Hill  also  imprisoned  guinea  pigs  for  periods  as  long 
as  fourteen  weeks  in  tight  cages  where  the  proportion 
of  carbon-dioxide  was  from  fifteen  to  thirty  times 
above  the  normal.  The  guinea  pigs  throve  beautifully 
in  spite  of  the  "bad"  air  as  long  as  their  cages  were 
kept  cool,  dry,  and  clean. 

In  other  experiments  Hill  was  able  to  prove  that 
breathing  the  hot  and  vitiated  air  had  nothing  what- 
ever to  do  with  the  symptoms.  Persons  who  stood 
outside  were  able  to  breathe  the  vitiated  air  of  the 
cabinet  tubes  without  experiencing  any  ill  effects. 
Conversely,  when  those  inside  were  suffering  extreme 
symptoms  due  to  the  overheated  and  stagnant  air  of 
the  cabinet,  they  experienced  no  relief  from  breathing 
the  pure,  outside  air  through  the  tubes.  Only  the  fans 
and  the  lower  temperature  brought  relief.  The  expla- 
nation is  as  follows :  If  the  air  is  not  in  motion,  that 


160    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

next  to  the  body  quickly  becomes  saturated  and  re- 
fuses to  take  up  additional  moisture.  It  acts  as  a 
"steam  jacket"  enveloping  the  body  and  causes  lan- 
guor and  depression.  The  perspiration  is  not  evapo- 
rated and,  as  the  Germans  say,  the  body  is  then  not 
able  to  "unwarm"  itself.  The  pulse  is  accelerated, 
more  blood  is  sent  to  the  skin  and  less  to  the  viscera 
and  brain.  The  blood  vessels  of  the  skin  dilate,  the 
blood  pressure  is  lowered,  and  extra  work  is  thrown 
upon  the  heart.  When  the  dead  air  is  set  in  motion 
by  a  fan,  the  steam  jacket  is  dissipated,  the  sweat 
evaporates,  the  circulation  becomes  more  normal,  and 
we  are  refreshed. 

Air  currents  and  perceptible  variations  of  tempera- 
ture are  the  essence  of  good  ventilation.  The  "imper- 
ceptible ventilation"  for  which  the  mechanical  engi- 
neer so  industriously  labors  is  beginning  to  look  like  a 
delusion  and  fraud.  The  thermostat l  has  well  been 
called  an  "invention  of  the  Devil."  It  is  largely  our 
prejudice  against  air  currents  and  variable  tempera- 
ture which  makes  our  indoor  life  so  unhealthful. 

By  some  hundreds  of  thousands  of  years  of  outdoor 
living,  before  houses  were  invented,  man's  body  be- 
came so  adapted  as  to  thrive  under  the  stimuli  of  air 
currents  and  changing  temperature.  Our  few  hundred 
years  of  life  in  the  stagnant  atmosphere  of  stuffy  rooms 
have  not  yet  brought  the  physiological  adjustment 
necessary  to  make  such  life  healthful.  Out  of  doors, 

1  A  mechanical  arrangement  which  works  automatically  so  as  tf> 
maintain  a  uniform  temperature  of  the  room. 


THE  PHYSIOLOGY  OF  VENTILATION       161 

even  in  a  very  mild  breeze,  the  body  is  bathed  in 
at  least  five  hundred  cubic  feet  of  air  per  minute.  It 
enjoys  complete  "perflation."  l  Open-air  schools  per- 
mit perflation;  others  do  not.  Indoor  schools  which 
have  to  depend  on  windows  for  their  ventilation  may  be 
more  healthful,  in  case  the  windows  are  frequently 
thrown  open  to  admit  a  fresh  supply  of  cool  air,  than 
those  with  the  most  improved  system  of  artificial 
ventilation. 

Normal  and  complete  perflation  can  injure  no  one 
whose  physical  defenses  have  not  been  weakened  by 
coddling.  Continued  sedentary  life  does  this.  As  stated 
by  Hill,  "Our  circulation  is  contrived  for  a  restless, 
mobile  animal"  (3).  Life  indoors  both  lowers  vitality 
and  increases  the  opportunities  for  contagion.  Persons 
who  have  been  weakened  by  hot-house  culture  have  to 
take  special  precautions  with  clothing  in  making  the 
transition  to  outdoor  life. 

Instead  of  fleeing  from  drafts,  we  should  seek  them. 
As  long  as  we  are  healthy,  it  is  only  the  little  draft, 
which  cools  but  a  small  part  of  the  body,  that  is  inju- 
rious. The  remedy  for  draft,  therefore,  is  more  draft, 
coupled  with  the  healthy  circulation  that  comes  from 
sufficient  exercise.  Even  the  sickly  pupils  of  the  open- 
air  school  do  not  catch  cold. 

Immunity  from  colds  depends  largely  upon  the 
healthy  action  of  the  automatic  vasomotor  reflexes  of 
the  skin.  When  the  body  needs  to  be  cooled,  the  walls 

1  Perflation  refers  to  the  rapid  movement  of  air  over  the  entire 
surface  of  the  body. 


162    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

of  the  blood  vessels  in  the  skin  relax  and  become  dis- 
tended with  blood  so  as  to  permit  more  rapid  loss  of 
heat  by  radiation  and  conduction.  When  heat  needs  to 
be  conserved,  the  blood  is  driven  from  the  skin  to  the 
interior  by  the  contraction  of  the  surface  blood  vessels. 
This  process  is  reflexly  controlled  by  a  delicate  nerv- 
ous mechanism  which  causes  the  walls  of  the  blood 
vessels  to  contract  or  relax  according  to  the  kind  of 
signal  received. 

Hardly  anything  is  more  to  be  desired  than  a  healthy 
condition  of  these  vasomotor  reflexes.  When  they  are 
normal,  drafts  do  not  harm  us,  and  we  can  expose  our- 
selves with  impunity  to  sudden  changes  of  tempera- 
ture. The  important  fact  to  be  noted  is  that  the  vaso- 
motor apparatus  can  be  kept  normal  only  by  practice. 
If  we  close  all  the  windows  to  prevent  drafts  and 
install  a  system  of  heating  which  keeps  the  tempera- 
ture of  the  air  at  exactly  the  same  point,  the  walls  of 
our  surface  blood  vessels  grow  lax  from  disuse  and  for- 
get how  to  act.  Then  when  the  draft  is  encountered, 
or  when  the  room  is  cooled  a  little  below  the  customary 
temperature,  or  when  we  go  out  of  doors  lightly  clad, 
the  body  is  too  rapidly  cooled.  This  is  the  way  we  train 
our  children  to  catch  cold.  No  other  results  need  be 
expected  until  the  windows  and  doors  are  thrown  open 
and  the  children  are  permitted  to  live  and  learn  under 
normal  conditions  of  air  and  with  less  suppression  of 
physical  activity. 

The  heart,  the  capillaries  of  the  skin,  the  sweat 
glands,  and  the  mechanism  for  producing  heat  by 


\^Ly^/4XX0JU>%^/* 


THE  PHYSIOLOGY  OF  VE 

increased  oxidation  must  all  function  together  in  order 
to  keep  the  body  at  a  constant  temperature,  and  the 
exact  participation  of  each  factor  varies  according  to 
the  temperature,  humidity,  and  currents  of  the  sur- 
rounding air.  The  balanced  cooperation  of  all  these 
reflex  controls  cannot  be  maintained  except  under 
fairly  normal  conditions  of  life.  The  sedentary  life  of 
the  school  disrupts  all  of  them.  The  mechanical  sys- 
tem of  ventilation  at  best  can  ventilate  only  the  school- 
room, while  the  real  end  of  school  ventilation  is  the 
aeration  of  the  individual  cells  of  the  child's  body. 
This  end  will  not  be  attained  until  we  fill  the  schools 
with  perceptibly  moving  air  of  ordinary  outdoor  hu- 
midity and  of  a  reasonably  low,  but  not  quite  uni- 
form, temperature;  nor  will  it  be  attained  until  we  per- 
mit the  child  to  lead  a  life  of  normal  activity. 

Another  of  the  serious  evils  of  schoolroom  air  under 
artificial  methods  of  ventilation  and  heating  isjdeficient 
humidity.  When  air  of  30°  F.  at  a  relative  humidity  of 
60  or  70  per  cent  is  heated  to  72°,  the  relative  humidity 
is  greatly  lowered  and  the  drying  capacity  of  the  air  is 
increased  enormously.  On  an  average  winter  day  the 
air  of  the  "best  ventilated"  school  may  show  a  rela- 
tive humidity  of  only  25  or  30  per  cent;  that  is  to  say,  S 
it  is  as  drying  as  the  winds  of  the  Sahara.  Plants  less 
hardy  than  the  desert  cactus  shrivel  and  die  in  such  an 
atmosphere.  Why  should  we  expect  children  to  thrive 
in  it? 

So  great  is  the  drying  capacity  of  warm  air  at  this 
degree  of  humidity  that  it  voraciously  licks  up  every 


gi.  ru*** 


V 

164    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

available  particle  of  moisture,  from  the  furniture,  which 
promptly  cracks  and  falls  to  pieces,  and  from  the  skin 
and  throats  of  the  children.  All  the  mucous  membranes 
exposed  to  such  air  become  parched  and  unhealthy. 

As  shown  elsewhere  (p.  200),  one  important  function 
of  the  nasaljmssages  is  to  add  moisture  enough  to  tl 
air  in  its  passage  to  the  lungs  to  raise  it  almost  to  the 
point  of  saturation.  In  the  desiccated  air  of  the  furnace- 
heated  or  steam-heated  school,  this  task  becomes  too ' 
great.    Diseased  conditions  of  the  nose  and  throat       ,^ 
result:  catarrh  becomes  the  rule;  diphtheria,  pneu- 
monia, and  tuberculosis  are  more  easily  contracted; 
and  it  is  possible  that  adenoids  and  hypertrophied  ton- 
sils may  sometimes  be  caused  in  this  way. 

When  the  mucous  membranes  of  the  nose  and  throat 


are  healthy,  they  produce  a  germicidal  secretion  which 
rids  the  incoming  air  of  nearly  all  its  bacteria.  When 
changed  hi  texture  by  air  of  deficient  humidity,  the 
membrane  is  no  longer  a  "bulwark  against  disease," 
but  a  "host  for  the  culture  of  germs."  "It  turns  traitor 
to  the  body  by  giving  aid  and  comfort  to  its  enemies." 

Another  effect  of  this  kiln-drying  to  which  we  sub- 
ject children  is  to  make  them  irritable  and  nervous. 
Self-control  becomes  more  difficult.  Outbreaks  of 
temper  are  frequent.  Concentration  is  impossible. 

It  has  been  suggested  that  some  of  the  evil  effects  of 
indoor  air  may  be  due  to  changes  which  heated  and 
inclosed  air  undergoes  in  respect  to  its  electric  proper- 
ties and  radio-activity.  The  physiological  effects  of 
radio-activity,  however,  are  yet  too  clouded  in  obscur- 


THE  PHYSIOLOGY  OF  VENTILATION      165 

ity  to  enable  us  to  speak  with  any  assurance  on  this      ^.-V^ 
point.  ^  »  \, 

The  experimental  evidence  seems  to  justify  the  9^ 
conclusion  that  living  in  stuffy  rooms  is  unhealthful 
mainly  because  of  the  excessively  high  temperature, 
unsuitable  humidity,  and  motionless  uniformity  of  in-     "*- 

•  •'  >  •         ^  •• —     .    ~  T>* 

closed  air,  combined  with  the  habits  of  physical  inact- 
ivity which  usually  go  with  this  mode  of  life.  If  this  7 
is  correct,  we  should  divert-the  rich  stream  of  public 
money  now  going  to  the  purchase  of  expensive  venti- 
lating systems  to  other  and  more  profitable  ends.  It 
would  be  a  step  in  the  progress  of  hygiene  if  we  could 
contrive  to  get  along  without  school  buildings  alto- 
gether. Where  this  is  not  possible  we  can  at  least  make 
our  schoolrooms  into  the  open-air  type  by  the  use  of 
large,  hinged  windows.  The  air  of  the  ordinary  indoor 
school  can  also  be  made  much  more  hygienic  by  fre- 
quent flushing  through  opened  windows.  The  latter 
precaution,  in  fact,  is  a  necessary  adjunct  to  any  sys- 
tem of  ventilation.1 

REFERENCES 

*1.  Karl  Brabbee:  "Heitzung  u.  Liiftung  von  Schulen."  Zt.  f. 
Schulges.,  Beiheft  to  no.  8,  1912,  pp.  59-75. 

*2.  Luther  H.  Gulick:  Report  of  Committee  on  Heating  and  Ven- 
tilation. Proc.  Sixth  Cong.  Am.  Sch.  Hyg.  Assoc.,  1912,  pp. 
195-202. 

*3.  Leonard  Hill:  "Stuffy  Rooms."  Pop.  Sci.  Mo.,  1912,  pp.  374-96. 
4.  Hough  and  Sedgwick:  The  Human  Mechanism,  1906,  pp.  564. 
(See  especially  pp.  162-76  and  187-210.) 

1  For  a  statement  of  the  effects  of  open-air  schools  upon  growth 
rate,  nutrition,  and  the  composition  of  the  blood,  see  Health  Work 
in  the  Schools,  by  Hoag  and  Terman.  Houghton  Mifflin  Company. 


166    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

5.  L.  W.  Hines:  "The  Effects  of  Schoolroom  Temperature  on  the 
Work  of  Pupils."  Psych.  Clinic,  1909,  pp.  106-13. 

6.  R.  G.  Macfie:  Air  and  Health,  1909,  pp.  345. 

*7.  Reichenbach:  "Heitzung  u.  Liiftung  von  Schulen."  Zt.  f. 
Schulges.,  1912,  Beiheft  to  no.  8,  pp.  28-59. 

*8.  Steinhaus:  "BeitrSge  zur  Frage  der  Ventilation  von  Klassen- 
raumen."  Zt.  f.  Schulges.,  1913,  pp.  6-32. 

*9.  F.  Verzar:  "The  Influence  of  Lack  of  Oxygen  on  Tissue  Respi- 
ration." Jour,  of  Physiol.,  1912,  pp.  39-52. 


CHAPTER  XI 

THE  TEETH  OF  SCHOOL  CHILDREN 

The  problem 

DR.  WILLIAM  OSLER  has  expressed  the  belief  that 
more  physical  degeneracy  can  be  traced  to  neglect  of 
the  teeth  than  to  the  abuse  of  alcohol.  It  is  undeni- 
able that  it  affects  directly  very  many  more  people. 
Of  our  twenty  million  school  children,  not  over  one 
or  two  million  are  free  from  dental  disorder  of  some 
kind,  and  of  the  remainder  of  the  population  only  a 
negligible  minority. 

About  one  fifth  of  all  the  teeth  of  our  school  chil- 
dren are  diseased.  Every  day  hundreds  of  thousands 
of  these  teeth  are  aching.  Dental  caries  has  been 
named  by  Dr.  Jessen  "the  people's  disease";  no 
other  is  so  widespread. 

Diseased  teeth  are  thought  to  be  responsible  for 
a  vast  amount  of  ill-health,  including  indigestion, 
anaemia,  general  debility,  mental  and  physical  re- 
tardation, nervousness,  and  acute  infectious  diseases. 
Complications  with  heart  and  ear  are  common.  Life 
expectancy  and  industrial  efficiency  depend  in  no 
small  degree  on  the  condition  of  the  teeth.  Moral 
efficiency  and  the  joy  of  living  may  depend,  directly 
or  indirectly,  about  as  much  on  one's  teeth  as  on 
one's  philosophy  or  religion.  Who  would  not  agree 


168    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

with  Don  Quixote,  that  a  tooth  is  worth  more  than  a 
diamond? 

Artificial  teeth,  to  be  sure,  may  be  substituted  for 
those  which  nature  gave  us,  but  since  their  mastication 
efficiency  has  been  demonstrated  to  be  only  about  one 
tenth  that  of  natural  teeth,  they  can  hardly  be  consid- 
ered a  satisfactory  substitution. 

During  the  Boer  War  over  3000  English  soldiers 
were  invalided  home  because  of  defective  teeth.  Out 
of  23,000  rejected  applications  for  enlistment  in  the 
British  army,  5000  were  for  defective  teeth.  In  1906, 
the  United  States  rejected  1000  applicants  for  the  same 
reason.  In  one  year  1845  soldiers  in  the  French  army 
were  sent  to  the  hospital  because  of  disorders  of  the 
teeth.  Loos  examined  the  teeth  of  1000  German  sol- 
diers and  found  an  average  of  9.6  carious  teeth  per 
head.  Cunningham  and  Rose  found  an  average  of  7.5 
and  6.9  per  head,  respectively.  The  German  soldiers 
examined  by  Port  had  27  per  cent  of  their  teeth  dis- 
eased (quoted  in  14).  These  are  probably  average 
conditions  for  adults  in  Europe  and  America. 

Yet  the  causes  of  dental  decay  are  definitely  known, 
tangible,  and  amenable  to  control.  About  twenty 
millions  of  dollars,  expended  in  the  right  way,  would 
put  all  the  teeth  of  all  our  school  children  in  order,  as 
far  as  their  present  state  of  disease  permits;  and  an 
annual  expenditure  of  fifty  or  seventy-five  cents  for 
each  child,  combined  with  suitable  instruction,  would 
keep  them  so.  Dental  decay  is  chiefly  a  disease  of  child- 
hood and  youth.  If  kept  in  repair  till  the  age  of 


THE  TEETH  OF  SCHOOL  CHILDREN      169 

twenty,  the  teeth  should  be  sound  at  sixty.  Neglected 
till  twenty,  teeth  with  any  tendency  to  decay  are  be- 
yond hope  of  salvage. 

What  examinations  of  children's  teeth  have  disclosed 

Two  decades  ago  the  mouth  of  the  school  child  was 
to  the  average  educated  person  an  unknown  quantity. 
Even  the  dentist  and  physician  were  not  aware  of  the 
actual  conditions  except  by  inference,  for  the  simple 
reason  that  only  5  or  10  per  cent  of  the  children  ever 
came  to  them  for  examinations.  It  remained  for  the 
school  doctor  and  school  dentist  to  ascertain  the  real 
facts. 

Examinations  of  thousands  of  school  children  in 
diverse  parts  of  the  world  have  shown  that  fewer  than 
10  per  cent  of  our  school  children  are  free  from  diseased 
teeth  or  gums,  dental  caries  (decay  of  teeth)  being  the 
most  common  defect.  The  average  school  child  has 
from  three  to  five  decaying  teeth.  Many  investigations 
report  as  many  as  20  to  30  per  cent  of  all  the  teeth  as 
affected. 

Pedley,  in  England,  examined  3800  children,  3  to  16 
years  of  age,  and  found  75  per  cent  with  diseased  teeth: 
12  per  cent  of  all  the  teeth  needed  filling  or  extraction. 

Rose's  statistics  include  157,361  children  in  Baden 
and  Thtiringen,  the  proportion  with  diseased  teeth 
running  from  79  per  cent  to  98  per  cent.  From  16  to 
35  per  cent  of  all  the  teeth  were  diseased. 

In  nineteen  cities  of  Schleswig-Holstein,  where  19,- 
725  children  of  6  to  15  years  were  examined,  only  5 


170    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

per  cent  were  free  from  dental  caries.  Only  218  of 
these  children  had  ever  been  treated  by  a  dentist;  a 
little  over  1  per  cent. 

Dr.  Jessen's  examination  of  10,000  school  children 
in  Strassburg  showed  95.7  per  cent  of  the  children  to 
have  a  total  of  102,456  decayed  teeth;  52,2 19  teeth  were 
missing  or  beyond  repair.  Of  646  children  of  kinder- 
garten age,  over  85  per  cent  had  diseased  teeth,  the 
average  number  per  child  being  slightly  above  4. 

Unghavari's  statistics  for  1000  Hungarian  children 
of  6  to  12  years  show  87  per  cent  with  defective  teeth: 
22.5  per  cent  of  the  milk  teeth  were  defective  and  7.75 
per  cent  of  the  permanent. 

In  Cambridge,  England,  Dr.  Cunningham  reports 
less  than  2  per  cent  of  about  3000  children  free  from 
dental  caries.  One  third  of  these  children  had  free  pus 
in  the  mouth  from  diseased  gums  or  teeth.  The  Brit- 
ish Dental  Association  found  only  1508  sets  of  good 
teeth  among  10,500  children,  while  the  average  number 
of  unsound  teeth  per  child  exceeded  3^.  Wallis  reports 
that  London  school  children  average  3.9  carious  milk 
teeth  and  2.8  carious  permanent  teeth  per  child;  and 
that  9.3  per  cent  of  London's  school  population  suffer 
from  alveolar  abscess  ("gum  boil"). 

In  New  South  Wales,  Australia,  7600  children 
showed  15  per  cent  of  the  permanent  teeth  in  a  carious 
condition,  and  32.5  per  cent  of  the  milk  teeth.  The 
average  number  of  carious  teeth  per  child  was  4.5. 

In  New  York  City  61  per  cent  of  266,426  children 
3xamined  had  defective  teeth,  but  less  than  one  fourth 


THE  TEETH  OF  SCHOOL  CHILDREN      171 

had  ever  entered  a  dentist's  office.  The  Dental  Asso- 
ciation in  Cleveland  found  15,061  cavities  in  the  teeth 
of  2677  children,  or  an  average  of  5.6  per  child.  Boston 
reports  33,575  school  children  as  in  need  of  dental  serv- 
ices, and  Brookline  77  per  cent.  Of  500  New  York 
children  who  in  1909  applied  for  certificates  permitting 
them  to  leave  school  to  go  to  work,  486  had  2808  de- 
cayed teeth;  only  5  per  cent  had  ever  visited  a  dentist 
except  for  an  extraction;  and  there  was  not  one  "de- 
cently clean"  mouth  in  the  500  (22). 

Smaller  cities  have  given  similar  results.  Superin- 
tendent Johnson  reports  dental  caries  in  96.9  per  cent 
of  497  children  of  Andover,  Massachusetts,  and  31.4 
per  cent  of  all  the  teeth  as  affected :  22.5  per  cent  of  the 
children  had  suffered  from  toothache  within  the  previ- 
ous week.  Superintendent  Reavis  examined  407  chil- 
dren in  Oakland  City,  Indiana,  and  found  only  53  with 
satisfactory  teeth  —  210  children  had  from  1  to  4  de- 
cayed, and  133  from  5  to  10;  44  children  had  all  four 
of  the  six-year  molars  in  a  carious  condition. 

Additional  investigations  are  summarized  in  the 
table  on  page  172. 

Our  estimate  of  90  per  cent  with  one  or  more  defec- 
tive teeth  is  therefore  conservative.  When  medical 
inspectors  (as  contrasted  with  dental  examiners)  re- 
port only  40  to  60  per  cent  with  defective  teeth,  we  are 
to  understand  that  such  low  figures  are  the  result  of 
superficial  inspection  without  probe  and  mirror.  It 
should  be  remembered  that  when  the  defect  has  pro- 
gressed so  far  as  to  be  obvious  at  a  hasty  glance,  the 


172    THE  HYGIENE  OF  THE  SCHOOL  CHILD 
TABLE  21 


Date 

Place 

Per  cent  with 
diseased  teeth 

Per  cent  of  all 
the  teeth  defective 

1902 
1894 

Aschaffenburg 
Berlin 

99 

99 

33 
31 

1897 
1897 

Freiburg 
Halle 

98 
94 

22 

1898 

Hannover 

89-93 

27 

1893 
1902 

Wurzburg 
Rudolstadt 

81-85 
93 

15 

28 

1904 
1900 

Augsburg 
Denmark 

99.4 
92 

21 

1897 
1898 
1902 

Italy 
Norway 
Russia 

92 
91 

82 

14 

1895 

Sweden 

86-100 

16-36 

1900 

Switzerland 

90-100 

14-35 

most  favorable  time  for  repairing  the  injury  has  gone 

by. 

Other  conditions  very  common  are  protruding 
upper  or  lower  teeth,  jaws  meeting  at  front  or  back 
only,  teeth  in  double  rows,  crowded,  etc.  As  Gant 
shows,  there  is  more  or  less  gum  disease  in  one  mouth 
out  of  three,  and  badly  diseased  gums  in  one  out  of 
twenty.  Uncleanliness  is  very  general,  and  but  a  small 
minority  have  ever  consulted  a  dentist  for  any  other 
treatment  than  extraction. 

Johnson's  description  (18)  of  the  average  school  child 
of  Andover  fits  a  large  proportion  of  children  in  every 
school.  "He  has  twenty-four  teeth;  eight  of  them  are 
diseased;  sixteen  of  them  are  discolored  with  unsightly 
accumulation  of  food  and  deposits,  or  else  he  has  some 
noticeable  malformation  interfering  with  mastication; 
three  of  the  four  six-year  molars  are  seriously  affected, 


THE  TEETH  OF  SCHOOL  CHILDREN      173 

or  else  one  is  already  lost  and  another  decayed.  He 
has  never  put  a  toothbrush  to  his  teeth,  has  had 
toothache  more  or  less  during  the  past  year,  and  has 
never  seen  the  inside  of  a  dentist's  office." 

Age  differences  are  marked.  Owing  to  the  approach- 
ing secondary  dentition,  more  diseased  teeth  are  found 
in  the  lower  than  in  the  intermediate  grades.  The 
smallest  number  is  found  at  about  ten  years.  In  New 
York  the  ages  below  ten  averaged  one  third  more 
carious  teeth  than  the  ages  above  ten.  By  the  age  of 
fourteen,  however,  so  many  of  the  permanent  teeth  are 
decayed  that  the  number  of  defective  teeth  per  child 
is  as  great  as  at  six  or  seven.  The  six-year  molars  as  a 
rule  begin  to  decay  within  two  years  after  then*  appear- 
ance, so  that  by  the  age  of  ten  years  one  or  more  of 
them  are  unsavable. 

No  sex  differences  worthy  of  note  have  been  made 
out  except  that  the  girls  are  slightly  more  precocious  in 
dentition,  having,  after  the  age  of  six  years,  an  average 
of  one  more  permanent  tooth  than  boys  of  the  same  age. 

Injuries  produced  by  defective  teeth 

Defective  teeth  may  affect  the  health  of  the  entire 
body.  The  influence  is  chiefly  of  four  kinds:  (1)  De- 
creased power  of  mastication,  due  either  to  decay  o* 
irregularities  of  the  teeth;  (2)  the  toxic  effect  of  puij 
which  is  absorbed  directly  into  the  blood  or  taken  into 
the  stomach  and  intestines;  (3)  reflex  nervous  dis- 
turbance due  to  pain,  impaction  of  teeth,  etc. ;  and  (4) 
the  possibility  of  acting  as  a  breeding-ground  and 


174    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

distributing-point  for  the  bacteria  which  cause  acute 
infectious  diseases. 

Thorough  mastication  is  prevented  by  defective 
teeth.  This  is  due  to  lack  of  chewing  surface,  to  irreg- 
ularities which  prevent  the  teeth  from  meeting  evenly, 
and  to  local  tenderness.  Many  children  from  6  to  12 
years  are  deprived  of  half  the  normal  chewing  surface. 
The  loss  of  one  tooth  always  means  the  functional  loss 
of  its  opposite.  Malformation  of  the  jaws,  as  in  severe 
cases  of  adenoids  or  impaction  (crowding),  makes 
mastication  practically  impossible  for  many  children. 

Mastication  has  a  larger  function  than  merely  to 
prepare  the  food  for  swallowing.  When  thoroughly 
performed  it  trebles  or  quadruples  the  amount  of 
saliva,  mixes  it  thoroughly  with  the  food,  and  initiates 
one  of  the  essential  processes  of  digestion,  the  conver- 
sion of  starch  into  sugar.  This  is  the  only  part  of 
digestion  over  which  we  have  direct  voluntary  control. 

Mastication  also  provides  a  necessary  stimulus  for 
the  healthy  development  of  the  jaw  and  the  growth  of 
the  teeth.  It  has  been  shown  experimentally  with  rab- 
bits that  filing  the  teeth  on  one  side,  so  as  to  confine 
mastication  to  the  other  side,  causes  maldevelopment 
of  the  jaws  and  of  the  bones  about  the  nose  and  the 
base  of  the  skull.  Finally,  when  mastication  is  thor- 
ough, the  teeth  tend  to  clean  themselves  during  the 
meal;  when  food  is  bolted  the  teeth  are  more  prone 
to  decay. 

Toxaemia  from  the  swallowing  and  absorption  of  pus 
is  probably  the  most  serious  evil  of  neglected  teeth. 


THE  TEETH  OF  SCHOOL  CHILDREN     175 

Every  cavity  becomes  filled  with  a  mixture  of  decayed 
food  and  bacteria.  Miller  has  segregated  and  identi- 
fied more  than  one  hundred  different  kinds  of  mouth 
bacteria,  several  of  which  are  known  to  be  injuri- 
ous. 

The  germs  of  tuberculosis  and  diphtheria  are  often 
found  in  dental  cavities  and  are  thought  sometimes  to 
find  their  way  into  the  body  from  this  point.  Decayed 
and  neglected  teeth  may  in  this  way  cause  tubercu- 
losis, scarlet  fever,  diphtheria,  etc.  When  the  teeth  are 
decayed,  the  tonsils  are  also  more  likely  to  become  dis- 
eased. Gibson  found  that  1.8  per  cent  of  the  children 
with  sound  teeth  had  enlarged  tonsils;  3.7  per  cent  of 
the  children  with  1  to  4  carious  teeth;  and  5.3  per  cent 
of  those  with  4  or  more. 

The  following  table  of  results  from  Brown's  investi- 
gation confirms  Gibson's  conclusions  (2). 

TABLE   22 


Number  of 
carious  teeth 

Number  of 
children 

Percentage  with  ton- 
sils enlarged  beyond 
size  of  a  filbert 

0 

1803 

7.5 

1-4 

3502 

12.5 

over  5 

1678 

16.2 

When  the  decay  has  spread  well  into  the  interior  of 
the  tooth,  there  is  always  danger  that  the  pus  will  find 
its  way  down  through  the  small  opening  to  the  point 
of  the  root  and  there  cause  the  infection  commonly 
known  as  an  alveolar  abscess  ("gum  boil,"  or  "ulcer- 
ated tooth").  As  shown  in  the  accompanying  illustra- 


176    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


tion,  decay  causes  the  death  of  the  tooth,  gangrene  of 
the  pulp,  and  discharge  of  pus  through  the  root.  This 
infects  the  surrounding  tissues,  causing  soreness  of  the 
tooth  and  jaw,  until  finally  the  abscess  breaks  through 
to  the  surface  of  the  jaw  and  allows  the  pus  to  escape. 
A  sinus  remains,  however,  which  continues  to  discharge 
more  or  less  pus  as  long  as  the  tooth  remains,  or  until 
it  is  hollowed  out,  disinfected,  and  filled  (22).  This 
chronic  stage  may  cause  no  observable  symptoms  in 
the  mouth,  but  the  pus  constantly  finds  its  way  into 
the  remainder  of  the  alimentary  tract  and  into  the 
blood. 

Pedley  says  that  the  only  fit  analogy  to  the  chronic 
gum  boil  is  the  serpent's  tooth,  through  the  hollow  of 
which  the  deadly  venom  is  injected  into  the  flesh  of  its 
victim.  If  there  is  pus  in  the  mouth  arising  either  from 
decayed  teeth  or  diseased  gums,  some  of  it  will  be 
mixed  with  the  food  during  the  process  of  mastication 
and  swallowed.  The  constant  absorption  of  millions  of 
virulent  bacteria  causes  a  septic  condition  of  the  intes- 
tines, resulting  in  irritation  of  the  intestinal  linings, 
catarrh,  diminished  secretions,  anaemia,  and  general 
weakness.  The  bacteria  may  be  carried  by  the  blood  to 
distant  parts  of  the  body,  giving  rise  to  glandular  dis- 
turbances, inflammation  of  the  heart,  etc.  The  child 
with  extreme  oral  sepsis  is  likely  to  be  sallow,  thin,  and 
nervous. 

The  statistics  indicate  that  more  than  1  per  cent  (a 
quarter-million)  of  our  school  children  are  constantly 
suffering  from  one  or  more  ulcerated  teeth.  Pus  may 


THE   PHENOMENA  OF  DENTAL  CARIES  AND  THE   DEVELOPMENT  OF 
AN  ABSCESS  (Pedley  and  Harrison) 

A.  Normal  tooth  tissues  with  commencing  caries  at  A. 

B.  Cavity  formed  through  enamel  into  dentine  by  means  of  acid  bacteria.  Irri- 
tating pulp  and  causing  swelling  of  the  blood  vessels,  inflammation  and  pain. 

C.  Death  of  the  blood  vessels  and  infection  of  the  pulp  cavity  with  septic  germs 
from  the  mouth.    Inflamed  vessels  around  raising  tooth  in  socket.   Pain  on  biting. 

D.  Opening  into  pulp  cavity  plugged  with  food  or  debris  preventing  escape  of 
•decomposing  gases  at  A  and  forcing  a  passage  at  B  forms  an  abscess  which  dis- 
charges at  C  as  a  gum-boil. 


THE  TEETH  OF  SCHOOL  CHILDREN      177 

arise  also  from  other  affections  of  the  gums  and  teeth, 
and  is  sometimes  found  free  in  the  mouths  of  30  per 
cent  of  the  school  children  (8). 

Bad  teeth  may  cause  nervousness  either  indirectly  by 
causing  malnutrition  or  directly  from  the  reflex  irrita^ 
tion  which  aching  or  crowded  teeth  produce.  Motor 
automatisms  sometimes  result  and  moral  self-control 
may  become  impossible.  Even  choreif orm  movements 
and  epileptiform  seizures  may  occur.  Dr.  Jessen  exam- 
ined the  teeth  of  31  stammerers  and  stutterers  and 
found  nearly  twice  the  usual  amount  of  defectiveness 
(14). 

Another  investigator *•  examined  58  persons  with  the 
skiagraph  (an  instrument  for  recording  irregularities 
of  the  teeth)  and  found  that  all  who  suffered  impaction 
showed  signs  of  nervous  disorder.  The  symptoms 
ranged  from  headaches  and  restlessness  to  epilepsy, 
and  from  mild  insomnia  to  dementia  prcecox.  The  same 
author  reports  that  six  out  of  eight  such  cases  recov- 
ered upon  relief  of  the  impaction.  It  is  significant  that 
in  no  case  was  there  any  local  pain,  and  in  only  a  few, 
pain  of  any  kind. 

Holmes  (12)  describes  an  interesting  case  of  moral 
delinquency  and  nervous  instability  which  appeared 
to  be  the  result  of  impacted  teeth.  The  boy  became 
irritable,  nervous,  and  restless,  gradually  developing 
incorrigibility  and  habits  of  lying  and  stealing.  He 
was  brought  before  the  juvenile  court,  treated  for 
adenoids,  etc.,  to  no  avail.  Finally  a  dental  examina- 
1  See  Monthly  Cydop.  and  Med.  Bull.,  November,  1909. 


178    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

tion  was  made  which  disclosed  an  extraordinary  condi- 
tion of  impacted  teeth.  Treatment  was  followed  by 
return  to  nervous  control  and  complete  moral  reform. 
While  it  cannot  be  denied  that  suggestion  may  have 
been  partly  responsible  for  this  reform,  much  clinical 
evidence  has  been  adduced  to  show  that  reflex  irrita- 
tions may  be  caused  by  defective  teeth.  As  for  tooth- 
ache, every  one  recognizes  the  havoc  it  may  wreak  in 
a  few  hours  on  the  moral  habits  of  a  lifetime. 

Defective  teeth  and  mental  development 

On  classifying  his  pupils  as  bright,  average,  or  dull, 
Johnson  found  that  among  the  children  with  good 
teeth  there  were  13  bright  children  to  10  dull,  while 
among  those  with  bad  teeth  there  were  only  8  bright 
children  to  12  dull.  In  New  York,  Ayres  found  that 
among  3304  boys  10  to  14  years  of  age  42  per  cent  of 
the  dullards  had  defective  teeth,  40  per  cent  of  those 
with  average  intelligence,  but  only  34  per  cent  of  those 
classed  as  bright.  The  average  progress  made  in  a 
given  period  by  the  children  with  good  teeth  was  4.94 
years,  and  by  children  with  defective  teeth  4.65;  a  loss 
of  about  6  per  cent.  Dr.  Edwin  Collins  *  had  already 
claimed  a  positive  correlation  between  good  teeth  and 
scholarship,  but  offered  little  data  hi  support  of  his 
argument. 

The  problem  involved  is  one  whose  solution  de- 
mands carefully  planned  research.  Only  one  investiga- 
tion of  this  type  is  available  on  the  issue  in  question, 
1  See  Nineteenth  Century,  July,  1899. 


THE  TEETH  OF  SCHOOL  CHILDREN      179 

the  Cleveland  study  undertaken  by  Dr.  Wallin  and 
the  Oral  Hygiene  Committee  of  the  National  Dental 
Association  (33).  The  investigation  proposed  to  meas- 
ure by  means  of  suitable  tests  the  influence  of  proper 
care  and  treatment  of  the  teeth  upon  the  improvement 
of  mental  capacities  in  school  children.  Forty  pupils, 
"repeaters,"  were  chosen  for  the  tests.  The  teeth  were 
first  put  in  order  and  the  pupils  were  pledged  to  cany 
out  a  prescribed  regimen  of  mouth  cleanliness  and 
thorough  mastication.  A  prize  was  stipulated  for  all 
who  lived  up  to  the  rules,  and  those  who  became  care- 
less were  dropped  from  the  test  group.  The  fidelity  of 
the  pupils  in  following  instructions  was  checked  up  by 
a  visiting  nurse.  Twenty-seven  pupils  were  available 
for  the  entire  experiment,  which  extended  over  the 
period  of  one  year.  The  pupils  were  first  tested  in 
May,  1910,  before  dental  treatment  began;  at  the 
opening  of  school  in  September;  and  again  in  May, 
1911.  The  functions  tested  involved  (1)  visual  memory 
(reproduction  method) ;  (2)  rapidity  of  thought  (verbal 
associations);  (3)  speed  and  accuracy  in  adding  digits; 
(4)  association  as  measured  by  the  "opposites"  test; 
and  (5)  speed  and  accuracy  of  visual  discrimination 
("  A-test ").  At  the  close  of  the  year  the  pupils  showed 
a  fairly  uniform  improvement  hi  all  the  tests  of  approxi- 
mately 50  per  cent.  Improvement  in  school  work  was 
simultaneous,  only  one  of  the  twenty-seven  pupils  fail- 
ing of  promotion.  This  is  an  excellent  record,  consider- 
ing that  the  pupils  tested  belonged  to  the  retarded 
class. 


180    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

A  serious  defect  of  Wallin's  study,  however,  lies  in 
the  fact  that  no  "control"  group  was  tested.  It  is 
therefore  impossible  to  say  how  much  of  the  observed 
improvement  was  due  to  improved  adjustment  to  the 
later  tests,  how  much  to  the  added  year  of  age,  and 
how  much  to  the  dental  treatment  and  mouth  hygiene. 
Nevertheless,  it  is  significant  that  improvement  in 
school  progress  occurred  simultaneously  with  improve- 
ment in  the  tests.  Other  investigations  of  this  type 
should  be  made  under  better  controlled  conditions. 

Effects  upon  health  and  growth 

It  has  been  noticed  by  several  investigators  that 
children  with  bad  teeth  are  extremely  likely  to  be 
below  normal  size.  Johnson  found  children  with  good 
teeth  to  average  one  half-year  ahead  of  children  of  the 
same  age  whose  teeth  were  bad.  Wallis  (34)  says  that 
he  has  found  children  with  severe  oral  sepsis  (discharge 
of  pus)  nearly  always  under  weight  and  frequently 
below  grade.  Henneberg  (11)  found  that  children  with 
good  teeth  gained  5  per  cent  more  in  weight  and  nearly 
10  per  cent  more  in  height  during  one  school  year  than 
children  with  bad  teeth.  The  following  are  typical 
cases  described  by  Colyer  (4,  p.  168  ff .) :  — 

(1)  A  girl  of  4 §  years,  considerably  below  normal  weight, 
was  suffering  from  severe  gastro-intestinal  trouble.  Several 
decayed  teeth  were  filled  or  removed,  following  which  the 
girl  gained  four  pounds  in  four  months,  or  twice  the  normal 
gain  for  the  age  in  question.  (2)  A  girl  of  three  years  weigh- 
ing 24  pounds  developed  tenderness  of  the  teeth  and  lost  1 J 


THE  TEETH  OF  SCHOOL  CHILDREN      181 

pounds  in  one  month  (February).  The  deciduous  molars 
were  removed  and  local  treatment  applied  to  the  incisors. 
Within  one  month  the  child  increased  2|  pounds.  By  Sep- 
tember 3,  the  weight  was  27^  pounds.  The  incisors  now  be- 
gan to  give  trouble,  and  the  child  was  seen  October  6,  when 
its  weight  had  fallen  to  25f  pounds.  Attention  to  these  teeth 
was  followed  by  progressive  and  normal  increase  in  weight. 

Only  two  or  three  studies  are  available  which  fail  to 
support  the  usual  medical  opinion  that  defective  teeth 
are  injurious  to  health.  One  of  these  was  an  investiga- 
tion made  by  the  school  doctors  of  Magdeburg,  Ger- 
many, in  1910-11,  and  reported  by  Dr.  Henneberg 
(11).  The  procedure  in  the  experiment  consisted  in 
selecting  from  each  schoolroom  five  poorly  nourished 
and  five  well  nourished  children  and  subjecting  them 
to  dental  examination,  to  measurement  of  height, 
weight,  and  chest  girth,  and  to  year-long  observation 
for  contagious  disease.  On  the  basis  of  his  own  150 
cases  Henneberg  denies  any  significant  relationship 
among  the  traits  in  question  and  states  that  the  other 
22  school  doctors  were  led  to  the  same  conclusion. 

For  two  reasons,  however,  the  conclusions  of  the 
Magdeburg  school  doctors  do  not  seem  warranted  by 
the  data  of  the  investigation.  In  the  first  place,  they 
ruled  out  of  the  investigation  (1)  all  children  from  the 
poorest  homes;  (2)  all  of  tubercular  heredity;  (3)  all 
vacation  colony  children  (the  pre-tuberculous) ;  and  (4) 
those  subject  to  frequent  illness.  These  four  classes 
are,  of  course,  just  the  ones  in  whom  the  extreme  influ- 
ences of  defective  teeth  are  most  likely  to  be  detected. 


182    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

In  the  second  place,  their  data  do  show  certain  sig- 
nificant differences.  Of  the  badly  nourished,  61  per 
cent  had  "bad"  teeth  (four  carious  teeth,  or  more);  of 
the  well  nourished,  only  52  per  cent.  Bad  teeth  were 
therefore  more  than  one  sixth  less  frequent  with  the 
well  nourished.  During  the  year  children  with  good 
teeth  gained  an  average  5  per  cent  more  in  weight  and 
10  per  cent  more  in  height  than  those  with  bad  teeth. 
On  selecting  the  22  children  having  the  very  worst 
teeth  and  comparing  them  with  the  22  having  the 
very  best,  the  following  important  differences  were 

found: — 

TABLE  23 

Poorly  nourished  Well  nourished 

With  worst  teeth  (22)  9  13 

With  best  teeth    (22)  14  8 

Of  the  children  38  were  suffering  from  marked  anae- 
mia, and  of  these  28  had  "bad "  teeth  and  only  10  had 
"good"  teeth.  The  actual  correlation  is  too  obvious 
to  require  further  comment. 

Dr.  Henneberg's  conclusion,  denying  any  relation- 
ship, seems  to  rest  on  the  erroneous  premise  that  if 
such  a  correlation  existed  it  would  hold  for  every  in- 
dividual case,  and  that  the  child  with  poor  teeth  would 
always  be  found  inferior  in  nutrition,  height,  weight, 
blood  composition,  susceptibility  to  contagious  disease, 
etc.  Such,  however,  would  be  the  case  only  if  bad  teeth 
were  the  sole  cause  of  the  defective  conditions  named. 
This,  of  course,  is  maintained  by  no  one.  In  reality  the 
data  should  be  interpreted  as  supporting,  rather  than 


THE  TEETH  OF  SCHOOL  CHILDREN      183 

discrediting,  the  conclusions  which  have  resulted 
from  clinical  evidence  against  defective  teeth. 

On  the  other  hand,  we  must  avoid  attributing  to 
defective  teeth  conditions  which  are  due  to  other 
causes.  Thiele's  examinations  of  1500  children  enter- 
ing school  in  Chemnitz  (Germany)  showed  that  chil- 
dren classed  as  having  "unsatisfactory"  teeth  (four  or 
more  defective)  did  not  differ  materially  from  those 
having  "satisfactory"  teeth  (less  than  four  defective) 
as  regards  nutrition,  rickets,  tuberculosis,  adenoids, 
heart  defects,  discharging  ear,  or  speech  defects  (30). 

Dr.  Ernst's  study  of  the  dental  conditions  of  500 
boys  entering  school  in  Kiel  (Germany)  also  gave  little 
correlation  between  the  condition  of  health  and  the 
number  of  carious  teeth  except  when  the  latter  num- 
bered nine  or  more.  Ernst  agrees  with  Henneberg  that 
in  such  cases  the  decayed  teeth  are  less  the  cause  than 
the  result  of  low  general  vitality  (7). 

A  complete  reinvestigation  of  the  problem  is  ur- 
gently needed.  In  further  studies  of  this  type,  the 
classification  of  pupils  according  to  dental  defective- 
ness  should  be  made  on  a  finer  scale.  Classification 
into  two  groups  only,  those  with  "good"  teeth  and 
those  with  "bad,"  is  needlessly  coarse  for  statistical 
purposes. 

The  cause  of  dental  caries 

The  salient  facts  of  dental  caries  have  been  suc- 
cinctly stated  by  Pedley  and  Harrison  (23,  pp.  75-76) 
as  follows :  — 


184    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

1.  Dental  caries  always  commences  on  the  outside,  and  is 
due  to  external  causes. 

2.  Fermentation  and  putrefaction  of  particles  of  food  are 
effected  by  the  ever-present  bacteria,  and  this  involves  the 
production  of  acids. 

3.  The  enamel  is  attacked  at  one  spot,  some  places  being 
more  vulnerable  than   others,  especially  in  crevices  where 
food  has  the  opportunity  of  resting. 

4.  The  enamel  prisms  are  split  up  and  disintegrated. 
When  the  dentine  is  reached,  the  acid-forming  bacteria  dis- 
solve out  the  lime  and  leave  a  softened  area. 

5.  The  dentinal  tubules  are  invaded,  and  they  become 
swollen  and  dilated. 

6.  Liquefying  bacteria  dissolve  the  tubes  and  the  gelat- 
inous matrix. 

7.  Further  disintegration  of  enamel,  with  dissolution  of 
the  dentine,  leads  to  the  formation  of  a  cavity,  in  which 
food  and  bacteria  find  a  resting-place. 

8.  Gradually  the  pulp  is  infected. 

9.  Owing  to  inflammatory  action,  the  nerve  tissue  is  irri- 
tated, the  blood  pressure  is  increased,  and  the  vessels  be- 
come dilated. 

10.  Pus  appears  in  isolated  spots,  and  the  whole  tissue 
dies. 

11.  This  is  followed  by  decomposition  and  putrefaction. 

12.  When  this  septic  material  is  forced  through  the  root 
an  abscess  (gum  boil)  is  the  result,  accompanied  with  fever 
and  general  malaise. 

The  mouth  is  an  ideal  culture  medium  for  germ  life 
because  of  the  warmth,  moisture,  and  nutritive  ma- 
terial afforded.  Streptococcus  and  staphylococcus, 
both  pus  producers,  are  always  in  the  mouth.  Pneu- 
mococcus  (the  germ  causing  pneumonia)  and  the  tu- 


THE  TEETH  OF  SCHOOL  CHILDREN      185 

bercle  bacillus  are  frequently  found.  On  the  basis  of 
partial  counts  it  has  been  estimated  that  a  moderately 
unclean  mouth  may  harbor  more  than  a  billion  bac- 
teria. 

The  enamel  and  dentine  are  not  broken  down  by  the 
bacteria  directly,  but  by  the  acids  produced  by  the 
action  of  bacteria  upon  the  food  particles  left  in  the 
mouth.  The  problem,  therefore,  is  the  prevention  of 
acids.  The  saliva,  which  is  slightly  alkaline,  helps  to  do 
this.  In  ill-health,  however,  the  saliva  may  lose  part  or 
all  of  its  neutralizing  power;  and  what  is  still  more  im- 
portant, food  remnants  that  are  left  thickly  plastered 
in  the  recesses  of  the  teeth  protect  a  part  of  the  deposit 
from  the  effect  of  the  saliva  and  so  permit  the  destruc- 
tive processes  to  begin.  Recessive  gums,  mouth  breath- 
ing, and  accumulations  of  tartar  have  also  this  effect. 

The  rate  of  acid  formation  depends  in  part  upon  the 
nature  of  the  food  particles  left  in  the  mouth,  the  car^ 
bohyd  rates  being  the  foods  which  most  readily  ferment 
and  produce  acids.  For  this  reason  a  meal  should  not 
end  with  jams,  jellies,  cake,  candy,  or  other  foods  rich 
either  in  starch  or  sugar,  nor  should  these  be  eaten 
between  meals.  When  sweets  are  eaten,  they  should  be 
followed  by  solid  foods,  such  as  apples,  which  have  a 
cleansing  effect.  The  high  susceptibility  in  this  coun- 
try to  dental  caries  may  be  partly  accounted  for  by  the 
fact  that  our  sugar  consumption  per  capita  is  by  far 
the  highest  in  the  world.1 

1  Merritt  gives  this  as  92j  pounds  per  capita,  or  15  pounds  higher 
than  our  closest  competition. 


186    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

Whatever  the  food,  the  essential  problem  is  that  of 
keeping  the  mouth  clean.  The  main  obstacles  to  this 
are  three:  (1)  dental  irregularities;  (2)  the  use  of  soft, 
sloppy,  or  pasty  foods;  and  (3)  insufficient  mastication. 
Wallace  (32)  has  convincingly  shown  that  even,  well- 
matched  teeth  clean  themselves  in  the  thorough  mas- 
tication of  solid  foods,  and  that  they  do  this  more  effec- 
tively even  than  the  toothbrush.  If  the  food  is  pasty, 
however,  mastication  plasters  it  so  tightly  against  the 
teeth  that  no  ordinary  amount  of  brushing  removes  it. 
Wallace  believes  that  the  choice  of  solid  food  and  its 
deliberate  mastication  are  more  important  preventive 
measures  than  any  amount  of  artificial  cleanliness. 
His  opinion  is  based  on  over  6000  experiments  made  for 
the  purpose  of  determining  differences  in  the  tendency 
of  different  foods  to  lodge  in  the  mouth. 

In  order  to  try  the  theory,  Wallace  secured  parental 
cooperation  hi  subjecting  fourteen  children  to  a  test. 
From  the  age  of  three  or  four  years  they  were  given 
foods  of  high  tooth-cleansing  power  and  were  required 
to  masticate  thoroughly.  After  each  meal  the  mouth 
was  rinsed.  At  the  age  of  five  to  seven  years  not  one 
of  the  children  had  a  carious  tooth. 

When  a  tooth  is  sore,  mastication  is  shifted  to  the 
other  side  of  the  mouth  or  else  slighted  altogether. 
The  teeth  consequently  do  not  clean  themselves,  par- 
ticularly on  the  involved  side,  and  caries  results. 
Moreover,  as  already  pointed  out,  deficient  mastica- 
tion leads  to  maldevelopment  of  the  jaws  and  result- 
big  dental  irregularities.  This,  in  turn,  adds  another 


THE  TEETH  OF  SCHOOL  CHILDREN      187 

obstacle  to  thorough  mastication  and  hinders  the  self- 
cleansing  process.  Decay  once  started  tends  to  spread 
to  adjacent  teeth  mainly  for  the  reason  that  the  sore- 
ness interferes  with  mastication  on  the  involved  side 
and  the  teeth  of  that  side  become  clogged  with  food 
remnants. 

It  is  largely  for  the  above  reasons  that  the  care  of 
the  temporary  teeth  is  so  important.  When  neglected, 
as  they  usually  are,  thorough  mastication  is  out  of  the 
question  and  the  jaws  do  not  properly  develop.  The 
palate  tends  to  become  arched,  and  the  permanent 
teeth  are  almost  sure  to  come  in  crowded  or  uneven. 
Wallace  even  believes  that  irregular  teeth  and  arched 
palate  are  more  the  cause  of  adenoids  than  their  result, 
and  that  if  larger  use  were  made  of  solid  foods,  if  mas- 
tication were  always  thoroughly  performed,  and  if  the 
temporary  teeth  were  carefully  preserved,  adenoids 
would  rarely  develop. 

At  any  rate,  irregularities  of  the  teeth  are  known  to 
be  extremely  productive  of  caries  and  should  always  be 
corrected.  It  is  estimated  that  about  80  per  cent  of 
adults  have  one  or  more  dental  irregularities  predispos- 
ing them  to  caries.  Pits  and  crevices  in  the  teeth, 
however  caused,  act  as  lodging-points  for  food,  are 
difficult  to  cleanse,  and  are  therefore  always  the  start- 
ing-points for  decay. 

Thus  far  we  have  considered  the  immediate  cause,  the 
presence  in  the  mouth  of  acid-forming  bacteria.  An- 
other factor  of  great  importance  is  the  tooth's  power  of 
ief ense.  If  the  enamel  is  thin  or  defective  in  structure, 


188    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

disintegration  is  made  easy.  It  is  well  known  that 
individuals  differ  enormously  in  their  natural  resistance 
to  dental  caries.  Some  teeth  remain  perfectly  sound 
without  the  slightest  care;  others  require  all  the  arts  of 
dentistry  to  hold  them  together.  We  must  consider, 
therefore,  the  tooth's  nutrition. 

Both  sets  of  teeth  are  formed  and  embedded  in  the 
jaw  long  before  the  end  of  pre-natal  life.  When  the 
milk  teeth  are  beginning  to  appear,  the  enamel  of  the 
permanent  teeth  is  already  developing.  As  far  as  is 
known,  enamel  once  formed  changes  little  for  better  or 
for  worse  from  natural  causes.  We  must  go  through 
life  with  our  original  dental  armaments.  There  is  no 
second  dispensation.1  When  nutrition  is  insufficient 
during  infancy  and  childhood,  the  teeth  are  very  likely 
to  be  imperfect.  Growing  cells  cannot  build  a  perfect 
structure  without  suitable  material. 

The  main  cause  of  infantile  malnutrition  is  artificial 
feeding.  Michael2  investigated  the  relation  of  dental 
caries  to  infant  feeding  in  11,762  children.  Those  who 
had  been  suckled  ten  months  or  more  had  only  9  per 
cent  of  their  teeth  carious;  those  fed  on  cow's  milk,  22 
per  cent;  those  whose  principal  diet  was  oatmeal  water, 
27  per  cent.  Children  suckled  six  months  had  teeth 
correspondingly  inferior  to  those  suckled  ten  months. 

Rose's  study  of  157,000  children  shows  the  same  thing. 

*^V\  p 
EvenNthe  mother's  milk  is  sometimes  inferior,  due  to 

1  While  this  is  certainly  true  in  the  main,  some  authorities  make 
allowance  for  the  possibility  of  slight  physiological  changes  in  the 
enamel  after  the  tooth  has  attained  its  growth. 

8  Quoted  by  Colyer. 


THE   REPLACING   OF  THE  TEMPORARY  TEETH 

Showing  the  rudimentary  permanent  teeth  embedded  below  the  roots  of  the  temporarj 

teeth 

From  A  Handbook  of  Health,  by  Woods  Hutchinson,  M.D.  Houghton  Mifflin  Company, 

publishers 


BEFORE   AND   AFTER 

Plaster  of  Paris  casts  showing  results  of  orthodontia 
(Courtesy  of  Dr.  C.  S.  McCowen,  Palo  Alto,  Cal.) 


THE  TEETH  OF  SCHOOL  CHILDREN      189 


worry,  overwork,  alcoholism,  specific  disease,  etc. 
Jewish  children,  who  as  a  rule  are  breast-fed  and  other- 
wise well  cared  for,  are  much  less  subject  to  dental 
caries  than  other  children  (23). 

The  following  table  from  Ernst  (7)  shows  the  strik- 
ing correlation  between  the  number  of  carious  teeth  in 
children  entering  school  and  infant  malnutrition:  — 

TABLE  24 


Rickets 

Bottle 
children 

Breast- 
fed 
3  to  6 
mos. 

Breast- 
fed 
6  to  9 
mos. 

Breast- 
fed 
9  to  12 
mos. 

Breast- 
fed 
12  mos.-r- 

Number  of  carious 
teeth. 

8  25 

6  25 

4  8 

4 

33 

3. 

Per  cent  of  children 
with  perfect  teeth 
Distribution  of 
those  with  nine  or 
more  carious 
teeth  

0. 

1.14% 
64.  % 

6.63% 

22.     % 

16.% 

22.% 

16.4% 
14.  % 

21.3% 
14.  % 

Since  the  enamel  of  the  permanent  teeth  is  in  process 
of  formation  throughout  the  early  years  of  childhood, 
temporary  disturbances  of  nutrition,  such  as  measles, 
scarlet  fever,  etc.,  often  leave  horizontal  rings  of  micro- 
scopic pits  around  the  enamel. 

Rose  finds  a  correlation  between  the  prevalence  of 
dental  caries  and  lime  deficiency  in  the  soil.  In  regions 
with  least  lime,  caries  was  present  with  from  98  to  98.7 
per  cent  of  the  children;  where  the  proportion  of  lime 
was  greatest,  the  number  affected  ran  as  low  as  79  to 
82.8  per  cent  (27). 

Rose  and  Underwood  have  demonstrated  the  closest 
relation  between  dental  caries  and  the  degree  of  civili- 


190    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

zation.  All  primitive  races  are  practically  immune, 
regardless  of  food  habits  and  of  habitat.  Native 
Africans  are  practically  immune,  also  Eskimos.  The 
former  clean  their  teeth  religiously  after  each  meal,  the 
Eskimos  never.  Natives  of  India,  Malays,  and  Austra- 
lians are  also  little  affected. 

It  has  not  been  demonstrated,  however,  that  the 
difference  is  one  of  racial  heredity.  From  an  examina- 
tion of  many  skulls,  Underwood  shows  that  dental 
caries  is  ten  times  as  prevalent  in  western  Europe  to- 
day as  it  was  one  hundred  years  ago.  European  skulls 
of  the  eighteenth  century  average  about  one  decayed 
tooth  each;  those  of  to-day  about  ten.  Smith  (31) 
examined  over  50,000  Egyptian  skulls  and  found  prac- 
tical immunity  up  as  far  as  4000  B.C.  ;  after  that  a  rapid 
increase.  Of  500  "aristocratic"  skulls  dating  from  the 
pyramid  epoch,  only  50  were  free. 

It  hardly  seems  possible  that  actual  racial  degener- 
acy as  regards  the  power  of  the  teeth  to  resist  decay 
could  establish  itself  so  universally  in  a  few  genera- 
tions. Nor  is  it  necessary  to  assume  such  degenera- 
tion. Underwood,  who  has  made  the  most  extensive 
researches  in  this  field,  holds  that  the  facts  are  readily 
explained  in  terms  of  changed  food  habits.  Cooked, 
mushy,  and  sticky  foods  have  replaced  foods  that  were 
resistant  and  fibrous.  The  consumption  of  sweets  has 
been  multiplied  many  times.  Mastication  can  more 
easily  be  slighted.  This  tends  to  produce  irregularities 
of  the  teeth  and  maldevelopment  of  the  jaws.  Babies 
are  less  often  nourished  in  the  natural  way,  and  all 


THE  TEETH  OF  SCHOOL  CHILDREN      191 

through  childhood  there  is  a  deficiency  of  the  sunlight, 
air,  and  activity  necessary  to  healthy  growth.  The 
disease  is  a  disease  of  civilization. 

For  these  and  other  reasons,  the  prevention  of  dental 
caries  is  becoming  a  more  difficult  problem  than  ever 
before.  If  the  disease  is  not  arrested,  micro-organisms 
will  soon  score  their  first  complete  victory. 

Prevention 

Appropriate  preventive  treatment  during  childhood 
would  probably  insure  good  teeth  to  a  majority  of 
adults.  Preventive  measures  should  include  especially 
cleanliness,  thorough  mastication,  suitable  food,  the 
care  of  the  temporary  teeth,  nutrition  during  infancy 
and  childhood,  the  prevention  of  decay,  the  preven- 
tion of  irregularity,  and  the  repair  of  defects  as  rapidly 
as  they  appear.  To  this  end  the  school  can  make  two 
contributions  of  the  greatest  importance:  (a)  It  can 
instruct  children  more  thoroughly  than  it  now  does  in 
the  essentials  of  mouth  hygiene;  and  (6)  it  can  under- 
take preventive  and  curative  treatment  in  school  den- 
tal clinics. 

(a)  The  teaching  of  mouth  hygiene.  The  common 
practice  among  authors  of  textbooks  in  physiology  and 
hygiene,  of  dismissing  the  subject  of  teeth  with  a  page 
or  two,  touching  mostly  on  their  anatomy,  is  indefen- 
sible. Instead  of  such  summary  treatment  the  whole 
subject  should  be  thoroughly  canvassed.  The  brief 
presentation  of  a  few  essential  facts  relating  to  their 
anatomy  should  be  followed  by  a  fuller  discussion  of 


192    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

the  importance  of  good  teeth  for  health,  the  causes  of 
dental  decay,  and  the  means  of  its  prevention.  Th« 
instruction  should  be  extended  over  several  years,  and 
liberal  use  should  be  made  of  plates,  wall  charts,  and 
illustrative  material.  Health  rules  for  the  teeth  could 
well  be  pasted  in  the  backs  of  all  schoolbooks. 

Special  effort  must  be  centered  on  making  the  instruc- 
tion carry  over  into  action.  Health  instruction  \\ iih- 
out  health  habits  is  vain.  Children  should  be  taught  in 
the  school  how  to  rinse  the  mouth,  to  gargle,  and  to 
brush  the  teeth.  Actual  drills  for  this  purpose  are  to 
be  commended.  The  sentiment  of  disgust  may  be 
advantageously  enlisted  in  the  interest  of  mouth  clean- 
liness. 

Factors  which  influence  the  growth  and  decay  of  the 
teeth  in  infancy  cannot,  of  course,  be  reached  directly 
by  the  school.  They  may  be  reached  indirectly,  how- 
ever, by  the  education  of  girls  and  young  women  for 
the  duties  of  motherhood. 

(6)  The  school  dental  clinic.  The  school  should  offer 
treatment  as  well  as  instruction.  The  universal  preva- 
lence of  dental  caries  has  been  sufficiently  shown ;  like- 
wise that  it  is  folly  to  expect  the  parents  of  to-day  to 
deal  adequately  with  the  problem  on  their  own  initia- 
tive. Parents,  unfortunately,  are  too  likely  to  be  satis- 
fied as  long  as  the  tooth  does  not  ache.  It  is  an  excep- 
tional father  who  knows  what  the  lips  of  his  children, 
conceal.  Thousands  of  them  have  never  essayed  a 
glance  into  the  ulterior  of  the  mouth  they  work  so 
devotedly  to  feed.  In  the  most  aristocratic  suburb  of 


THE  TEETH  OF  SCHOOL  CHILDREN      193 

Boston  75  per  cent  of  the  children  had  never  been  to 
a  dentist.  Not  over  5  per  cent  of  the  children  in  the 
United  States  regularly  receive  the  dental  treatment 
they  need.  Even  physicians  are  likely  to  neglect  their 
opportunities  to  give  advice  about  the  care  of  the  teeth. 

The  six-year  molars  are  especially  subject  to  decay 
and  are  usually  mistaken  by  parents  for  temporary 
teeth.  Consequently  they  are  usually  neglected  till  the 
day  of  salvage  has  gone  by.  Dr.  Mary  Gallup,  of 
Boston,  examined  the  mouths  of  3000  adult  Americans 
and  found  only  7  complete  sets  of  six-year  molars.  Dr. 
Henie,  of  Norway,  found  over  40  per  cent  of  the  six- 
year  molars  diseased  by  the  end  of  the  eighth  year  and 
60  per  cent  by  the  end  of  the  fifteenth  year.1 

In  fact,  there  is  no  other  matter  of  health  where  the 
proverbial  ounce  of  prevention  will  go  so  far.  Dental 
caries  is  a  disease  of  childhood  and  youth.  "The  per- 
son whose  teeth  are  neglected  till  the  age  of  twenty  is 
already  a  lost  cause."  "When  a  tooth  has  ached,  the 
best  time  for  saving  it  has  gone  by."  To  preserve  in  a 
sound  condition  the  teeth  of  an  entire  family  costs  no 
more  than  the  belated  treatment  of  a  single  tooth.  To 
insure  the  necessary  treatment  no  other  means  is  as 
cheap  or  effective  as  the  school  clinic.2 

Finally,  orthodontia 3  should  be  encouraged.  There 
is  no  reason  why  the  child's  health  should  be  jeopard- 

1  Quoted  by  Burnham. 

2  For  a  discussion  of  school   dental  clinics  see  Health  Work  in 
the  Schools,  by  Hoag  and  Terman.   Houghton  Mifflin  Co. 

1  The  mechanical  treatment  of  dental  irregularities  and  deformi- 
ties of  the  jaw. 


194    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

ized  and  his  face  made  repulsive  just  because  his 
parents  lack  the  knowledge  or  the  money  to  remedy  the 
defect.  Nothing  hi  the  way  of  dental  irregularity  is  bad 
enough  to  be  hopeless  if  taken  in  hand  early  enough. 
A  little  girl  known  to  the  writer  had  at  the  age  of  ten 
years  the  facial  appearance  of  an  idiot.  The  palate 
was  arched  high  and  pointed  at  the  front  like  the  letter 
V.  The  upper  teeth,  already  projected  beyond  the  lips, 
were  so  crowded  that  one  appeared  entirely  within  the 
V.  The  child  suffered  constantly  from  indigestion  and 
headaches.  Four  years  of  orthodontia  transformed  the 
repulsive  face  into  one  of  absolutely  normal  appear- 
ance and  brought  every  tooth  to  its  proper  position. 
The  anaemia  and  headaches  disappeared  simulta- 
neously. The  plate  facing  page  188  illustrates  the  mira- 
cles that  are  constantly  being  wrought  by  orthodontia. 

Some  indications  of  dental  defects 

Unclean-looking  teeth. 

Unsound-looking  teeth. 

Unhealthy-looking  gums. 

"Gum  boils." 

Crooked  teeth. 

Prominent  teeth. 

Offensive  breath. 

Toothache. 

Admission  of  never  having  been  treated  by  a  dentist. 

Neglect  of  daily  use  of  toothbrush. 

Headache. 

Enlarged  lymph  glands  in  the  neck. 


THE  TEETH  OF  SCHOOL  CHILDREN      195 

Indigestion. 

General  malnutrition.1 

REFERENCES 

1.  W.  H.  Allen:  Civics  and  Health.    (Chap,  ix.) 

2.  H.  M.  Brown:  "The  Relationship  between  Enlarged  Tonsils 
and  Carious  Teeth."    School  Hygiene,  1913,  pp.  24-25. 

*3.  W.  H.  Burnham:  "The   Hygiene  of  the  Teeth."   Fed.  Sem., 

1906,  pp.  293-306. 
*4.  J.  F.  Colyer:  Dental  Disease  in  Relation  to  General  Medicine. 

1911,  pp.  190. 

*5.  W.  S.  Cornell:  Health  and  Medical  Inspection  of  School  Children. 

1912,  pp.  305-23. 

6.  George   Cunningham:   "Dental   Conditions   in   Elementary- 
School  Children."   In  Kelynack's  M ed.  Insp.  of  Schools,  chap. 

XII. 

7.  Dr.  Ernst : "  Dental  Examinations  in  Kiel  Elementary  Schools." 
Zt.  f.  Schulges.,  April,  1912,  pp.  241^*4. 

*8.  A.  W.  Gant:  "Dental  Treatment  of  School  Children  at  Cam- 
bridge."  School  Hygiene,  1911,  pp.  402-11. 
9.  Greve:  The  Prevention  of  Disease,  pp.  267-97. 
10.  B.  Gutenberg:  "Zum  Kapitel  der  Zahne  u.  Zahnpflege  bei  den 

Kindern."   Zt.  f.  Schulges.,  1901,  pp.  452-66. 
*11.  H.  Henneberg:  "Em  Beitrag  zur  Zahnfrage."  Zt.  f.  Schulges., 

1911,  pp.  894-911. 

12.  Arthur  Holmes:  "Can  Impacted  Teeth  Cause  Moral  Delin- 
quency?" Psych.  Clinic,  vol.  rv,  pp.  19-23. 

15.  W.  Hunter:  Oral  Sepsis  as  a  Cause  of  Disease. 

*14.  Dr.  Ernst  Jessen:   Die  Zahnpflege  in  der  Schule  mm  Stand-- 

punkt  des  Aerztes.   1909,  pp.  67. 
*15.  Dr.  Ernst  Jessen:  " Schulzahnpflege  u.  Schule."  Proc.  Second 

International  Congress  for  School  Hygiene,  1907,  pp.  495-502. 

16.  Dr.  Ernst  Jessen:    "Kostenpunkt  einer  Stadtischen   Schul- 
zahnklinik."   Inter.  Mag.  Sch.  Hyg.,  vol.  rv,  1908,  pp.  432-36. 

*17.  Dr.  Ernst  Jessen:  "Die  Zahnarztliche  Behandlung  der  Volk- 
schulkinder."  Inter.  Mag.  Sch.  Hyg.,  1907,  pp.  205-22. 

*18.  G.E.Johnson:  "Condition  of  Teeth  in  School  Children."  Fed. 
Sem.,  1901,  pp.  45-58. 

19.  E.  C.  Kirk:  "The  Dental  Disabilities  of  School  Children." 
Psych.  Clinic,  1910,  pp.  217-23. 

20.  Carl  Kuens:   " Gaumendef ekte  u.  ihre  Behandlung."     Zt.  f. 
Schulges.,  1911,  pp.  401-10. 

*21.  John  S.  Marshall:  Mouth  Hygiene  and  Oral  Sepsis.   1912,  pp 

262. 
*22.  Arthur  S.   Merritt:   "Mouth  Hygiene  and  its  Relation  to 

1  The  author  is  indebted  to  Dr.  T.  Sydney  Smith,  of  Palo  Alto, 
Cal.,  for  valuable  suggestions  in  the  preparation  of  this  chapter. 


196    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

Health."    In  The  Public  Health  Morement.    Published  by  Am. 
Acad.  Polit.  and  Soc.  Sci.,  1911,  pp.  228-42. 

*23.  Pedley  and  Harrison:  Our  Teeth:  How  Built  Up,  How  Destroyed, 
How  Preserved.  London,  1908,  pp.  97. 

24.  W.  H.  Potter:  "The  Care  of  the  Teeth  of  School  Children." 
Proc.  Am.  Assoc.  Sck.  Hyg.,  1912,  pp.  159-64. 

25.  W.  L.  Pyle:  Personal  Hygiene,  1910,  pp.  17-25. 

26.  W.  C.  Reavis:  "Dental  Examinations  of  School  Children." 
The  Elementary  Teacher,  1910,  pp.  90-98. 

27.  Karl  Rose:  "Die  Zahnpflege  in  den  Schulen."   Zt.f.  Schulges., 
1895,  pp.  65-87. 

28.  Dr.  Schlegel:  "The  Reading  (Pa.)  Free  Dental  Dispensary." 
Psych.  Clinic,  February,  1910. 

29.  Spokes:  "The  Care  of  the  Teeth  during  School  Life."  Proc.  1st 
Inter.  Cong.  Sch.  Hyg.,  vol.  in,  pp.  453-61. 

30.  Adolf  Thiele:  "Gebiss  u.  Kb'rperbeschaffenheit  der  Schulan- 
fanger."  Zt.  f.  Schulges.,  1910,  pp.  802-06. 

*31.  Arthur  S.  Underwood:  "The  Prevalence  of  Dental  Caries  in 
Modern  Civilized  Communities."  Nineteenth  Century  and 
After,  July,  1912. 

*32.  Sim  Wallace:  The  Prerention  of  Dental  Caries.   1912,  pp.  70. 

33.  J.   E.  W.  Wallin:  "Experimental  Oral  Euthenics."    Dental 
Cosmos,  April  and  May,  1912.    "Medical  and  Dental  Inspec- 
tion in  the  Schools  of  Cleveland."  Psych.  Clinic,  Januarv,  1910. 

34.  C.  E.  Wallis:  "The  Teeth  of  the  School  Child."  School  Hygiene, 
1910,  pp.  396-99.   (See  also  same  volume,  pp.  44-46.) 

*35.  C.  E.  Wallis :  School  Dental  Clinics:  Their  Foundation  and  Man- 
agement. London,  1913. 

*36.  Dr.  \Vimmenauer:  "  Schularzte  u.  Schulzahnhygiene."  Zt.f. 

Sckv'ge*.,  1911,  pp.  882-93. 

37.  Dr.  Wimmenaueru.  Dr.  Stephani^'Schulzahnklinikoderfreie 
Zahparztwahl."  Zt.f.  Schulges.,  1913,  pp.  225-43. 


CHAPTER  XII 

THE  HYGIENE  OF  THE  NOSE  AND  THROAT 
Written  with  the  assistance  of  Dr.  E.  B.  Hoag 

Relation  of  the  nose  and  throat  to  health 

THE  hygiene  of  the  nose  and  throat  during  child- 
hood is  important  for  several  reasons.  In  the  first 
place,  the  condition  of  the  respiratory  passages  deter- 
mines in  large  measure  our  susceptibility  to  many 
infectious  diseases.  It  is  now  well  established  that 
diphtheria,  scarlet  fever,  measles,  mumps,  whooping- 
cough,  infantile  paralysis,  influenza,  ordinary  colds, 
pneumonia,  and  tuberculosis  all  gain  entrance  to  the 
body  in  the  majority  of  cases  through  the  nose  or 
throat  passages.  Not  only  is  this  true,  but  the  secre- 
tions of  these  passages  are  capable  of  harboring  for  an 
extended  period  the  organisms  of  many,  if  not  all,  of 
the  diseases  mentioned.  In  such  cases  the  individual 
concerned  may  remain  a  "carrier"  long  after  he  him- 
self has  recovered.  This  fact  has  not  yet  been  demon- 
strated for  all  of  the  above-named  diseases,  but  it  has 
been  so  completely  and  satisfactorily  proved  in  respect 
to  diphtheria,  tuberculosis,  pneumonia,  and  infantile 
paralysis  that  we  are  justified  in  the  belief  that  it  occurs 
also  in  others. 

The  nose  and  throat  passages  are  provided  by  nature 
with  certain  safeguards  against  the  invasion  of  disease 


O  —  • 


198    TEE  HYGIENE  OF  THE  SCHOOL  CHILD 

germs.  These  include  the  tonsils  (the  pharyngeal  tonsil 
or  normal  adenoid  structure  of  the  back  part  of  the 
nose,  and  the  lingual  tonsil  on  the  back  of  the  tongue), 
the  mucous  secretions,  the  ciliated  cells  of  the  epithe- 
lium of  the  nose  and  bronchial  tubes,  and  the  hairs  lin- 
ing the  outer  portion  of  the  nasal  passages.  Anything 
that  interferes  with  the  health  of  these  passages  ren- 
ders the  body  more  liable  to  infection.  Consequently, 
adenoids  (overgrowth  of  the  third  tonsil),  enlarged 
inflamed  tonsils,  small  follicular  tonsils,  nasal  catarrh, 
or  obstruction  of  the  nasal  passages  by  means  of  polypi 
or  enlarged  turbinates,  all  tend  to  break  down  the 
natural  barriers  against  disease  germs.  Children  with 
adenoids  or  diseased  tonsils  nearly  always  suffer  from  a 
greater  number  of  children's  diseases  than  do  others, 
and  it  has  been  observed  time  and  again  that  such 
children  have  an  increased  tendency  to  tuberculosis, 
either  general  or  lymphatic  (i.e.,  of  the  lymph  glands 
of  the  neck).  The  occurrence  of  cervical  adenitis,  or 
inflammation  of  the  neck  glands  of  a  non-tubercular 
character,  is  frequently  observed  in  connection  with 
adenoids  or  diseased  tonsils  by  every  medical  officer  of 
schools. 

Tonsils  in  a  state  of  health  serve  as  guardians  against 
infection,  but  diseased  tonsils  not  only  lose  their  power 
to  protect  the  body,  but  actually  harbor  disease  germs 
and  their  poisonous  products.  These  facts  ought  to 
answer,  once  for  all,  the  question  as  to  the  advisability 
of  removing  diseased  tonsils  or  adenoids. 

While  it  is  well  known  that  inflammation  of  the 


THE  NOSE  AND  THROAT  199 

tonsils  (tonsillitis)  produces  fever  and  general  disabil- 
ity, it  is  not  so  generally  understood  that  both  the 
throat  tonsils  and  the  third  tonsil,  or  adenoids,  may  be 
diseased  without  the  knowledge  of  the  patient  and 
produce  fever  and  general  malaise.  This  is  particularly 
true  of  adenoids,  which  are  often  infected.  In  such 
cases  the  cause  of  the  fever  and  consequent  sickness  is 
often  regarded  as  obscure,  and  sometimes  the  real 
cause  is  not  discovered  at  all.  The  intimate  relation  of 
diseased  tonsils  and  adenoids  to  the  general  health  of 
the  body  is  most  important,  while  the  special  relation 
of  these  structures  to  acute  infections,  catarrh,  and 
deafness  is  so  important  as  to  demand  the  utmost  care. 

In  the  second  place,  obstruction  of  the  nasal  pas- 
sages forces  the  individual  to  "mouth-breathing." 
Why  should  it  be  a  matter  of  concern  whether  one  uses 
the  mouth  or  the  nose  for  a  breathing-passage?  The 
answer  is  that  the  nose  is  much  more  than  a  mere  tube 
for  breathing.  It  performs  at  least  five  important 
functions  which  the  mouth  can  perform  only  partially 
or  not  at  all. 

(1)  The  nose  acts  as  a  marvelously  effective  filter, 
clearing  the  inspired  air  of  nearly  all  its  dust  particles 
and  germs.  This  is  accomplished  chiefly  by  the  ciliary 
projections  of  the  mucous  linings,  which  intercept 
nearly  all  the  small  foreign  bodies  of  the  air  and  carry 
them,  by  means  of  constant  wave  motions,  to  the 
pharynx  and  mouth,  there  to  be  expelled.  If  the  mucous 
membranes  are  too  dry,  or  if  their  secretions  are  not 
normal,  as  in  catarrh,  this  function  of  the  nose  is  seri- 


200    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

ously  interfered  with.  In  case  of  mouth-breathing  the 
filtering  takes  place  to  only  a  slight  degree. 
»    vjL  .>    (2)  Due  to  the  shelf  -like  arrangement  of  the  turbi- 
^  nated  bones,  the  walls  of  the  nasal  passages  contain  .an 

extensive  surface  of  mucous  membrane.  This  is  sup- 
plied with  a  vast  system  of  blood  vessels  which  permit 
the  heating  of  the  air  in  its  passage  to  the  lungs.  The 
blood  sinuses  are  surrounded  by  involuntary,  erectile 
muscular  fibers  which  work  automatically  so  as  to  reg- 
ulate the  amount  of  blood  in  the  vessels  near  the  sur- 
face. When  we  go  out  into  a  cold  atmosphere  the 
amount  of  blood  in  these  vessels  is  quickly  increased 
to  permit  the  more  rapid  warming  of  the  air. 

(3)  The  arrangement  just  described  also  makes  pos- 
k^  sible  the  addition  to  inspired  air  of  a  great  deal  of 

moisture.  Air  which  is  received  at  20  to  40  degrees 
temperature,  and  which  contains  but  little  moisture, 
is  raised  almost  to  body  heat  and  becomes  two  thirds 
saturated  in  its  passage  through  a  healthy  nose.  The 
significance  of  this  for  health  lies  in  the  fact  that  the 
interchange  of  gases  in  the  lungs  is  largely  dependent 
upon  the  temperature  and  humidity  of  the  air  in  the 
lung  cells.  It  is  estimated  that  the  healthy  nose  adds 
to  the  inspired  air  about  one  pint  of  water  every 
twenty-four  hours. 

<^'ne  nose  *s  an  imP°rtant  organ  of  phonation. 
When  it  is  obstructed  by  adenoids,  enlarged  tonsils,  or 
polypi,  the  resonant  chamber  is  reduced  in  size,  giving 
the  thick  quality  of  speech  known  as  the  "nasal  voice." 
This  is  due  chiefly  to  the  interference  caused  by  nasal 


>*-   *- 

yO^ 


THE  NOSE  AND  THROAT  201 

obstructions  in  the  formation  of  overtones.  The  learn- 
ing of  a  modern  language  is  made  more  difficult,  and  in 
extreme  cases  certain  sounds  cannot  be  produced  at  all.1 

(5)  Mouth-breathing  eliminates  the  sense  of  smell. 
This  sense  may  have  less  importance  than  it  once  had, 
but  is  still  far  from  valueless.  It  not  only  acts  as  a 
warning  against  dangerous  gases  and  impure  air,  but 
has  also  an  aesthetic  value,  as  Helen  Keller  has  beauti- 
fully shown  us.2 

The  hygiene  of  the  nose  is  important  for  several 
other  reasons.  More  than  half  the  cases  of^deafness^ 
and  most  cases  of  partial  deafness,  are  caused  by  ob- 
structed breathing.  There  are  probably  one  million 
children  in  the  schools  of  the  United  States  who  are 
hard  of  hearing  from  this  cause.  Earache  and  ear- 
discharge  are  nearly  always  due  to  infection  which  has 
spread  from  an  unhealthy  nose  or  throat  to  the  middle 
ear  through  the  eustachian  tube.3  Diseased  air  pas- 
sages also  befoul  the  air  of  the  schoolroom  and  add  to 
the  difficulties  of  school  sanitation. 

Finally,  and  most  important  of  all,  mouth-breathing 
lowers  mental  efficiency,  causing  apathy,  dullness,  nerv- 
ous instability,  etc.,  with  consequent  school  retarda- 
tion. That  form  of  inattention  resulting  from  nasal 
obstruction  has  been  given  the  special  name  "apro- 
sexia  nasalis." 

In  a  valuable  study  Kafemann  tested  the  mental 

1  See  p.  200. 

*  Helen  Keller,  The  World  I  Live  In.  (Chap,  entitled  "Smell,  the 
Fallen  Angel.") 
»  Seep.  228 jf. 


202 

efficiency  of  two  groups  of  normal  subjects.1  Those  of 
one  group  had  the  nostrils  artificially  closed  during  the 
test;  those  of  the  other  group  were  permitted  normal 
respiration.  The  results  proved  that  artificial  stop- 
pages of  the  nasal  passages  for  even  a  few  hours  low- 
ered mental  efficiency. 

Enlarged  tonsils 

The  faucal  tonsils  are  the  ones  which  are  ordinarily 
spoken  of  as  "the  tonsils,"  and  are  situated  at  either 
side  of  the  root  of  the  tongue.  Normal  tonsils  are 
barely  visible,  but  enlarged  tonsils  range  from  the  size 
of  an  almond  to  that  of  a  large  English  walnut.  It  is 
not  difficult  to  see  the  tonsils  if  the  child  will  open  his 
mouth  wide,  relax  his  throat,  and  take  a  deep  breath, 
or  better,  pant.  A  wooden  tongue  depressor  may  be 
used  to  hold  down  the  tongue,  but  this  is  not  always 
necessary  in  routine  examination  after  a  little  skill  has 
been  acquired  in  the  management  of  the  child. 

The  normal  tonsils  appear  as  small,  oval,  smooth, 
pinkish  masses  of  lymphoid  tissue.  Any  marked  over- 
growth, holes  (crypts),  redness,  white  spots,  or  irregu- 
larity in  structure  indicate  abnormal  conditions.  Over- 
growth of  tonsils  in  young  children  is  extremely 
common,  and  may  occur  without  any  other  sign  of  dis- 
ease. In  fact,  this  condition  is  so  common  that  unless 
it  is  a  fairly  severe  case  many  physicians  consider  if 
best  to  disregard  it. 

Like  the  lymphoid  structures  of  the  neck,  the  tonsils 
1  The  "addition  test"  was  used. 


THE  NOSE  AND  THROAT  203 

are  often  somewhat  enlarged  without  causing  any  no- 
ticeable symptoms.  The  tendency  to  a  small  amount 
of  glandular  enlargement,  though  not  normal,  must  not 
be  unduly  emphasized.  In  many  cases  such  conditions 
tend  to  disappear  spontaneously  as  the  child  grows 
older  and  stronger.  On  the  other  hand,  it  should  not  be 
forgotten  that  marked  glandular  enlargement  indicates 
what  is  called  a  "lymphatic  diathesis,"  which  is  a 
serious  condition.  The  presence  of  a  chronic  inflam- 
mation always  undermines  the  health  more  or  less. 
Good  judgment  and  experience  are  required  in  esti- 
mating the  importance  of  enlarged  tonsils,  and  there  is 
probably  no  other  point  in  the  physical  examination 
of  children  on  which  examiners  so  greatly  disagree. 

Enlarged  tonsils  are  often  the  index  of  other  bad 
conditions.  Many  children  with  enlarged  tonsils  pre- 
sent also  such  symptoms  as  pallor,  anaemia,  malnutri- 
tion, and  enlargement  of  the  cervical  (neck)  glands.  In 
these  cases  all  the  lymphoid  tissues  of  the  throat  and 
neck  are  likely  to  be  infected,  the  child's  resistance  to 
disease  is  low,  and  the  entire  physical  organization 
needs  building  up. 

The  structures  most  often  affected  in  children  are 
the  faucal  (throat)  tonsils  and  the  post-nasal  tonsil,  or 
adenoids.  Adenoids  are  only  the  result  of  overgrowth 
of  the  third  tonsil,  and  do  not  represent  a  new  growth 
in  any  sense.  The  faucal  and  the  nasal  tonsils  are 
structurally  similar,  being  made  up  of  lymphoid  tissue. 
Like  all  other  lymphoid  tissues,  they  are  much  dis- 
posed to  hypertrophy  (enlargement)  during  childhood. 


204    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

The  function  of  the  three  tonsils  is  not  fully  known, 
but  it  is  believed  that  when  healthy  they  arrest  the 
entrance  of  disease  germs  into  the  lymphatic  vessels 
and  blood  stream.  Diseased  tonsils,  on  the  other  hand, 
are  thought  to  act  as  points  of  entrance  for  various 
kinds  of  infection.  It  is  believed  by  some  of  the  best 
authorities  that  rheumatism  frequently,  if  not  usually, 
invades  the  body  by  this  route.  At  any  rate,  a  previ- 
ous history  of  tonsillitis  is  often  discovered  in  cases  of 
articular  rheumatism.  As  shown  elsewhere  (p.  310), 
chorea  and  heart  disease  often  follow  an  attack  of 
acute  rheumatism.  Tonsillitis,  acute  rheumatism,  cho- 
rea, and  heart  disease  are  coming  to  be  regarded  as  a 
quartet  of  one  family. 

Whatever  may  be  the  useful  functions  of  the  tonsils, 
including  the  third  tonsil,  when  in  a  state  of  health, 
there  can  be  no  question  that  after  they  become  dis- 
eased, they  are  of  no  use  and  are  often  positively  harm- 
ful to  the  body. 

Diseased  tonsils  are  often  associated  with  defects  of 
the  nose.  The  explanation  is  simple  when  we  consider 
that  the  nasal  and  throat  passages  are  continuous,  and 
that  their  anatomical  structure  is  very  similar.  The 
throat,  nose,  eustachian  tube,  and  middle  ear  are  lined 
by  one  and  the  same  membrane.  Disease  of  any  part  of 
this  membrane  tends  to  spread  to  all  of  it.  The  inti- 
mate structural  relations  of  these  parts  are  shown  hi 
Fig.  16. 

Tonsils  may  be  enlarged  without  any  apparent 
inflammation,  and,  as  already  explained,  this  condi- 


THE  NOSE  AND  THROAT  205 

cion  is  not  always  to  be  regarded  as  especially  serious. 
Whether  overgrown  tonsils  should  or  should  not  be 
removed  will  depend  (a)  upon  the  degree  of  enlarge- 
ment, and  (6)  upon  the  cause  of  enlargement.  In  most 
cases  only  a  physician  of  experience  can  render  an 
intelligent  judgment.  Simple  enlargement  may  be 
only  a  part  of  a  general  lymphatic  disturbance,  and 
may  in  some  cases  have  existed  from  birth.  If  the  ton- 
sils are  so  large  as  to  interfere  with  breathing,  they 
should  certainly  be  removed.  One  frequently  sees  ton- 
sils of  this  character  so  large  as  to  meet  in  the  middle 
line  of  the  throat. 

Tonsils  may  be  enlarged  because  of  acute  or  chronic 
infection  causing  inflammation.  In  every  case  of 
acute  tonsillitis  there  is  some  such  enlargement,  which, 
however,  may  not  require  any  surgical  treatment.  On 
the  other  hand,  small  tonsils  are  often  diseased  and 
capable  of  producing  acute  tonsillitis.  In  such  in- 
stances they  practically  always  require  removal. 

Tonsils  which  are  chronically  enlarged  because  of 
inflammation  should  always  be  removed.  Such  tonsils 
often  have  crypts,  or  holes,  containing  cheesy  material, 
and  tonsils  of  this  character  are  not  only  offensive  but 
constantly  septic.  The  products  of  inflammation  fill 
the  crypts,  and  poisonous  materials  are  continually 
being  absorbed  into  the  system.  Cryptic  tonsils, 
whether  large  or  small,  are  rarely  treated  with  any 
success  by  other  means  than  total  removal.  In  a  word, 
tonsils  which  are  so  large  as  to  form  an  obstruction  to 
breathing,  and  those  chronically  inflamed,  whether 


206    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

large  or  small,  should  be  completely  removed.  Succes- 
sive attacks  of  tonsillitis  from  any  cause  usually  indi- 
cate the  necessity  of  surgical  interference. 

Ordinarily  this  can  be  properly  done  only  by  a  nose 
and  throat  specialist.  Many  operations  on  tonsils  are 
done  by  unskillful  operators  with  results  which  are 
disappointing.  If  the  tonsils  are  not  completely  re- 
moved they  are  likely  in  time  to  become  enlarged 
again.  Tonsils  completely  removed  do  not  return. 
Much  of  the  irregularity  seen  in  tonsils  is  due  to 
shrinkage  following  chronic  inflammation  or  incom- 
plete removal. 

The  proportion  of  school  children  who  suffer  from 
enlarged  or  otherwise  diseased  tonsils  is  fairly  constant. 
There  are  some  local  differences,  but  the  average  is 
about  the  same  for  the  whole  school  population.  Dr. 
Hoag  has  found  that  in  California,  for  some  unexplain- 
able  reason,  the  proportion  of  diseased  tonsils  is  con- 
siderably larger  than  in  Minnesota.  In  general  it  is 
safe  to  say  that  about  one  eighth  of  our  school  chil- 
dren suffer  from  this  defect.  The  proportion  is  consid- 
erably larger  for  children  under  ten  years  of  age  than  it 
is  for  those  older,  and  for  children  of  the  poor  than  for 
those  of  the  more  fortunate  classes. 

The  effects  of  diseased  tonsils  are  well  classified  by 
Cornell  as  follows:  — 

(1)  Obstruction  of  respiration  (usually  not  great) ; 

(2)  Increased  liability  to  throat  infections; 

(3)  Increased  liability  to  heart  infections  and  chorea; 

(4)  Increased  liability  to  tuberculosis; 


THE  NOSE  AND  THROAT  207 

(5)  Inflammation  of  the  cervical  glands; 

(6)  Lowered  general  vitality; 

(7)  Ear  involvement. 

No  child  with  chronically  diseased  tonsils  can  possi- 
bly be  well.  Furthermore,  he  is  constantly  in  danger 
of  attacks  of  tonsillitis,  diphtheria,  scarlet  fever,  or 
rheumatism,  and  he  is  rendered  abnormally  suscept- 
ible to  tuberculosis.  His  general  vitality  is  almost 
always  lowered  and  his  mental  processes  may  be  re- 
tarded. No  one  should  ever  hesitate  about  the  ques- 
tion of  removing  diseased  tonsils  from  the  throats  of 
children.  The  operation  is  safe  in  the  hands  of  a  skill- 
ful physician,  and  enormously  increases  the  child's 
possibilities  of  health,  happiness,  and  efficiency. 

Adenoids 

Adenoids,  as  already  stated,  consist  of  lymphoid 
tissue  forming  a  third  tonsil  and  are  situated  behind 
the  soft  palate  in  what  is  called  the  naso-pharynx.  It  is 
a  perfectly  normal  structure  until  it  becomes  over- 
grown or  infected.1  Adenoids  more  or  less  completely 
close  the  passage  between  the  nose  and  throat  and  in 
this  way  produce  the  condition  known  as  "mouth- 
breathing." 

The  adenoid  child  breathes  with  the  mouth  open 
because  it  is  impossible  for  him  to  breathe  in  any  other 
way.  He  usually  sleeps  with  his  mouth  open  and  com- 
monly snores.  The  obstruction  from  which  he  suffers 
is  rendered  much  worse  by  taking  cold,  for  the  reason 
1  Most  overgrown  adenoids  are  infected. 


208    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

that  adenoids  consist  of  a  soft  spongy  mass  of  tissue 
which  is  always  congested  (full  of  blood),  and  which 

becomes  much  more 
congested  when  the 
child  has  a  cold. 

Adenoids  are  some- 
times found  in  infants 
at  birth  or  soon  after, 
but  are  more  likely  to 
FIG.  15  be  observed  between 

A  passage  blocked  by  adenoids 

the  ages  of  3  and  10 

years.  After  puberty  (12  to  16  years)  they  tend  to 
disappear  and  are  seldom  found  in  adults;  but  in  those 
cases  in  which  they  have  been  allowed  to  "  absorb  " 
without  surgical  treatment,  unfortunate  results  always 
persist  as  evidence  of  the  neglect. 

There  are  three  reasons  for  the  greater  frequency 
of  adenoids  in  the  early  years  of  school  life.  (1)  The 
lymphatic  functions  play  a  much  larger  part  in  the 
child  than  in  the  adult,  and  the  lymphatic  are  there- 
fore more  prone  to  overgrowth.  (2)  As  adolescence 
approaches,  the  throat  enlarges  very  rapidly,  and  mark- 
edly relieves  the  crowded  condition.  At  the  same  time 
the  adenoids  themselves  are  reduced  in  size  by  shrink- 
ing and  partial  "absorption."  (3)  Many  of  the  older 
children  have  had  their  nose  and  throat  obstructions 
surgically  removed. 

The  proportion  affected  does  not  seem  to  vary  greatly 
in  the  different  countries  of  Europe  and  America. 
Kafemann  reports  7.8  per  cent  for  boys  and  10.6  per 


THE  NOSE  AND  THROAT 


209 


cent  for  girls.  Laaser  (9)  estimates  that  10  per  cent  of 
the  children  in  the  common  schools  of  Germany  have 
adenoids.  Of  9031  children  examined  in  Leipzig,  23.2 
per  cent  were  affected.  The  number  reported  by  the 
medical  examiners  in  Stockholm  was  13.8  per  cent  in 
1905,  and  12  per  cent  in  1906.  Another  Swedish  inves- 
tigation, by  Stangeberg,  reports  16  per  cent. 

Yearsley,  however,  on  the  basis  of  an  especially  care- 
ful study  of  2315  children,  estimates  that  37  per  cent 
of  the  pupils  in  the 
elementary  schools  of 
London  have  ade- 
noids (14).  Years- 
ley's  results  show 
that  of  those  who 
have  adenoids,  three 
fourths  have  also  en- 
larged tonsils,  and 
10.8  per  cent  ear 
complications.  Sex 
differences,  if  any 
exist,  are  not  great. 

The  experience  of 
Dr.  Hoag,  involving 
observations  of  more 
than  75,000  school  children  in  widely  different  parts 
of  the  country,  justifies  placing  the  number  at  8  per 
cent.  More  careful  examination  than  is  possible  in 
routine  school  work  would  probably  demonstrate  a 
still  larger  proportion  of  adenoid  children.  In  general, 


UPPER 

TOOTH 

LOWER 
TOOTH 


VOCAL 


FIG.  16 

A  clear  passage  to  the  lungs.    (Follow  the 
arrows.) 


210    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

adenoids  occur  somewhat  more  frequently  among  poor 
and  neglected  children  than  among  children  of  the 
better  classes.  This,  however,  is  equally  true  of  nearly 
all  kinds  of  common  physical  defects. 

Effect  of  adenoids 

Retardation  statistics  show  that  defects  of  breath- 
ing are  decidedly  more  common  among  retarded  chil- 
dren than  among  those  who  are  up  to  grade.  Comparing 
the  physical  conditions  of  1093  promoted  children  with 
those  of  303  who  failed  of  promotion,  Superintendent 
Verplanck,  of  South  Manchester,  Connecticut,  found 
adenoids  one  third  more  frequent  in  the  latter  group 
than  in  the  former.  In  a  study  of  449  retarded  chil- 
dren in  the  first  grade  in  Elmira,  New  York,  it  was 
found  that  of  those  who  had  been  in  this  grade  two 
years  19  per  cent  were  afflicted  with  adenoids;  of  those 
who  had  remained  in  the  grade  four  years  or  more,  50 
per  cent.  Statistics  by  Leonard  P.  Ayres,  collected  for 
the  purpose  of  ascertaining  the  relation  between  physi- 
cal defects  and  school  progress,  showed  that  obstructed 
breathing  was  66 1  per  cent  more  frequent  among  the 
dull  than  among  the  bright,  the  proportion  among  the 
bright,  average,  and  dull  being  9,  11,  and  15  per  cent, 
respectively.  Compared  with  children  having  no  de- 
fect, adenoid  children  showed  a  loss  of  14  per  cent  in 
rate  of  school  progress.  Children  with  hypertrophied 
tonsils  showed  a  loss  of  9  per  cent.1 

1  These  figures  are  based  upon  the  data  presented  in  chapter  xi  of 
Gulick  and  Ayres's  Medical  Inspection  of  Schools,  1913  edition. 


THE  NOSE  AND  THROAT  211 

Bonazzola  (quoted  in  5,  p.  60),  in  an  examination  of 
400  school  children,  found  141  who  displayed  symp- 
toms of  aprosexia.  Examination  of  the  141  showed 
adenoids  in  all  but  24  and  some  other  form  of  nasal 
obstruction  in  all  of  the  latter.  Wilbert  found,  in  a 
school  composed  of  375  boys,  26  who  were  described  as 
bad  scholars,  and  of  these,  22  had  adenoids. 

If  we  can  assume  that  10  per  cent  of  all  our  school 
children  suffer  from  obstructed  breathing,  and  if  we 
can  further  assume  that  their  instruction  at  school  is 
only  90  per  cent  effective  because  of  the  dullness  and 
ill-health  produced  by  this  defect,  then  the  money  loss 
from  this  source  alone  amounts  to  at  least  four  million 
dollars  annually.  However,  the  financial  aspect  of  the 
problem  is  much  less  important  than  the  pedagogical, 
moral,  and  humanitarian  considerations  involved. 

The  teacher  should  nevertheless  bear  in  mind  that 
adenoids  and  enlarged  tonsils  are  not  responsible  for 
all  the  dullness  found  among  school  children.  While 
marked  mental  improvement  often  follows  the  surgical 
removal  of  nasal  obstructions,  it  is  vain  to  hope  that 
stupidity  can  be  universally  eliminated  by  so  simple  a 
measure.  The  badly  retarded  child  is  usually  mentally 
and  physically  subnormal  by  endowment,  and  often 
his  physical  defectiveness  is  only  a  symptom  of  the 
subnormality,  not  its  true  cause.  There  is  danger  that 
the  influence  of  physical  defects  in  causing  retardation 
will  be  overemphasized :  it  is  so  much  easier  to  remove 
adenoids  than  it  is  to  ascertain  the  actual  causes  of 
retardation;  so  much  easier  to  rely  on  surgery  for  its 


212    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

cure  than  to  devise  the  needed  reforms  of  educational 
administration  and  pedagogical  procedure. 

By  questioning  teachers,  Cornell  (2)  investigated 
the  mental  effects  of  adenoid  removal  in  the  case  of  63 
children.  Of  these,  19  were  said  to  have  "improved 
much,"  25  to  have  "improved,"  16  to  have  remained 
unchanged,  and  3  to  have  deteriorated.  The  records  of 
subsequent  promotions  attained  by  these  pupils  were 
distinctly  less  favorable.  Out  of  97  opportunities  for 
promotions  in  the  months  following  the  operations 
there  were  61  failures. 

Yearsley's  valuable  study  of  London  children  (14) 
shows  that  only  in  severe  cases  are  adenoids  accom- 
panied by  the  so-called  "adenoid  face"  or  by  extreme 
aprosexia  (inability  to  attend).  Yearsley  defends  the 
view,  now  growing  in  favor,  that  adenoids  are  not  the 
sole  cause  of  the  abnormally  high  palate  so  commonly 
associated  with  them,  but  that  the  arched  palate  is  to 
some  extent  the  cause  of  the  adenoids;  likewise  that 
the  associated  irregularity  of  the  teeth  is  partly  due  to 
the  abnormal  palate  and  not  merely  to  the  presence  of 
adenoids.  At  any  rate,  adenoids  and  arched,  narrow 
palates  are  usually  found  together.  Dr.  N.  H.  Bul- 
lock's measurements  of  300  adenoid  and  300  normal 
children  of  the  same  age  showed  that  the  breadth  of 
upper  jaw  in  the  adenoid  children  averaged  .6  cm. 
below  that  of  normal  children. 

As  shown  in  chapter  xi,  mouth-breathing  and  irreg- 
ularities of  the  teeth  predispose  to  dental  caries. 

Such  mental  effects  as  are  produced  by  obstructed 


THE   PRIMARY   INCISION   FOR  SEPARATING   THE   HYPERTROPHIED 

TONSIL  FROM  ITS  ATTACHMENTS 

From  Phillips's  Diseases  of  the  Ear,  Nose  and  Throat.    By  permission  of  The 
F.  A.  Davis  Company,  Philadelphia 


BEFORE   AND   AFTER  REMOVAL  OF   ADENOIDS 


THE  NOSE  AND  THROAT  213 

breathing  have  not  been  satisfactorily  accounted  for. 
One  theory  is  that  adenoids,  particularly,  interfere 
with  the  nutrition  of  the  brain  and  with  the  removal  of 
its  waste  products.  This  was  the  explanation  offered  by 
Guye,  of  Amsterdam,  who  first  described  the  mental 
symptoms.  It  is  more  commonly  believed  that  the 
aprosexia  is  due  chiefly  to  chronic  toxaemia  (general 
poisoning)  produced  by  the  diseased  lymphoid  tissue, 
but  in  part,  also,  to  the  reduced  depth  of  respiration 
and  to  lowered  physical  activity.  Consideration  of  the 
hygienic  functions  of  the  nose  would  lead  us  to  expect  a 
gradual  reduction  of  vitality  when  these  functions  can- 
not be  performed. 

Whatever  may  be  the  correct  explanation  for  the 
frequent  association  of  adenoids  with  certain  physical 
and  mental  defects,  it  is  well  known  that  the  adenoid 
child  seldom  develops  normally.  He  is  usually  less 
active  and  less  inclined  to  play.  Kaster  and  Malherbe  l 
found  from  measurements  of  36  cases  that  growth  in 
height,  weight,  and  chest  girth  was,  on  the  average, 
three  times  as  rapid  in  the  month  immediately  follow- 
ing the  operation  as  in  the  month  preceding. 

Lung  capacity  and  the  shape  of  the  thorax  are  nearly 
always  affected  by  obstructed  breathing.  We  are  in- 
debted to  Dr.  N.  H.  Bullock,  medical  examiner  for  the 
schools  of  San  Jose,  California,  for  valuable  data  on 
this  point.  Dr.  Bullock  compared  the  front-to-back 
and  side-to-side  diameters  of  the  chests  of  300  ade- 
noid children  with  those  of  300  normal  children  of  the 
1  Quoted  by  Burnham. 


214    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

same  age.  Of  each  group  200  were  14  years  of  age; 
the  remaining  100  of  each  group,  7  years  of  age.  In  the 
case  of  the  14-year-olds,  the  side-to-side  diameter  of 
the  chest  averaged  1^  inches  below  normal  in  the 
adenoid  children,  and  the  front-to-back  diameter 
about  1  inch  above  normal.  This  gives  the  so-called 
"pigeon-breast"  ("barrel-chest,"  "funnel-chest," etc.) 
so  commonly  found  with  adenoid  children.  In  the  case 
of  the  7-year-olds,  the  breadth  of  chest  averaged  about 
one  third  inch  below  normal,  and  the  depth  of  chest 
about  one  half  inch  above  normal.  Of  the  adenoid 
children,  6  per  cent  at  6  years  and  16  per  cent  at  14 
years  had  the  "pigeon-breast,"  and  practically  all  of 
the  remainder  a  greater  or  less  degree  of  "  barrel-chest " 
or  "funnel-chest."  Among  the  non-adenoid  children 
there  was  not  a  single  marked  case  of  these  deformities. 
A  comparison  of  the  6-year-old  and  the  14-year-old 
adenoid  children  shows  that  the  deformity  of  thorax  is 
much  worse  in  the  latter.  The  adenoids  have  had  more 
time  to  do  their  injury. 

As  already  stated,  if  the  nasal  passages  are  healthy 
throughout,  the  air  which  is  breathed  is  rendered 
sterile  before  it  reaches  the  lungs.  This  is  true  even 
when  the  number  of  organisms  inhaled  runs  up  into 
the  thousands  per  hour.  But  if  adenoids  are  present, 
a  catarrhal  inflammation  takes  place  in  the  mucous 
linings  of  the  nose.  Three  things  result  from  this  con- 
dition, all  of  them  a  menace  to  health :  — 

(1)  The  air  is  not  properly  humidified  in  its  passage 
to  the  lungs; 


THE  NOSE  AND  THROAT  215 

(2)  it  is  not  sufficiently  warmed  before  reaching  the 
lungs;  and 

(3)  it  is  imperfectly  filtered  of  injurious  bacteria. 
Adenoids  are  also  frequently  the  seat  of  tubercular 

infection.  Pilet  found  1  case  tuberculous  in  10;  Brie- 
ger,  5  in  78;  Goltstein,  3  in  33;  Brindel,  8  in  64;  Lewin, 
10  in  200;  Rethi,  6  in  100;  Poliakov,  4  in  50,  etc.  (5,  p. 
66).  Peters  found  tuberculosis  in  45  per  cent  of  905 
adenoids. 

It  is  not  necessary  to  exaggerate  the  evils  of  ade- 
noids in  order  to  place  proper  emphasis  on  the  hygiene 
of  nose  and  throat.  There  is  no  common  type  of  defec- 
tiveness  more  serious  as  regards  ultimate  consequences 
for  health  than  diseased  conditions  of  the  upper  respir- 
atory passages.  The  ultimate  injury  far  exceeds  the 
immediate.  A  given  adenoid  child  may  be  able  to  keep 
out  of  the  sick-bed  and  to  make  a  fairly  creditable 
showing  in  school,  but  may  nevertheless  fail  on  account 
of  this  defect  to  develop  normal  vitality.  Many  years 
after  the  close  of  school  life,  such  a  child  is  likely  to 
prove  an  easy  prey  for  infectious  diseases  and  may  pay 
the  penalty  of  neglect  by  a  premature  death. 

Causes  of  adenoids 

Many  explanations  have  been  given  to  account  for 
the  presence  of  adenoids,  no  one  of  which  is  altogether 
satisfactory.  Among  the  most  common  explanations 
are  the  following:  — 

(1)  The  "lymphatic  constitution"  (supposedly  he- 
reditary). 


216    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

(2)  Poor  nutrition,  and  especially  rickets  and  latent 
tuberculosis. 

(3)  Thumb-sucking  and  the  use  of  the  "pacifier." 

(4)  General  unhygienic  conditions  of  life,  such  as 
injurious  dust,  excessively  dry  and  overheated  atmos- 
phere, etc. 

(5)  Infectious  diseases  of  childhood,  especially  neg- 
lect of  colds,  whooping-cough,  etc. 

(6)  Deviation  of  the  septum  (partition  between  the 
nostrils)  or  the  presence  of  other  partial  obstructions  to 
nasal  breathing. 

The  preventability  of  adenoids  and  diseased  tonsils 
is  a  question  which  has  received  less  consideration 
than  it  deserves.  The  fact  that  all  of  the  causative  fac- 
tors above  enumerated,  except  the  first,  are  largely 
subject  to  control,  suggests  that  appropriate  preven- 
tive measures  might  accomplish  a  great  deal.  Even 
the  heredity  factor  may  be  eliminated  by  the  practice 
of  eugenics,  once  the  laws  of  transmission  are  better 
understood. 

Suggestions  for  observation 

The  signs  and  symptoms  of  adenoids  may  be  grouped 
as  follows:  — 

Nasal  voice  and  defects  of  articulation; 
Mouth-breathing ; 
Catarrh  of  nose  or  throat; 
Pronounced  tendency  to  colds; 
A  heavy  or  stupid  expression; 
An  unusual  fullness  of  the  eyes; 
Slow  mentality  (often  retardation); 


THE  NOSE  AND  THROAT  217 

Poor  physical  development  (often  deficiency  in  play  life); 
Earache; 
Ear-discharge; 

Deafness,  or  partial  deafness; 
Crooked  or  prominent  upper  teeth; 
A  high,  arched  roof  of  the  mouth; 
Snoring; 
Disturbed  sleep; 
Loud  breathing  during  the  day; 
Undeveloped  facial  bones; 

Nervous  instability,  shown  by  peevishness,  finical  habits, 
etc. 

Some  but  not  all  the  indications  just  enumerated 
will  always  be  found  present  with  adenoids.  The  signs 
most  important  for  teachers  and  parents  to  note  are 
the  following:  — 

Open  mouth  and  snoring  at  night  (often  with  restlessness) ; 

Nasal,  expressionless  voice; 

Mouth-breathing  during  the  day; 

Heavy  facial  expression; 

Mental  dullness  or  apathy; 

High,  arched  palate; 

Crooked,  prominent  upper  teeth. 

Other  throat  symptoms  may  be  listed  as  follows:  — 

Complaints  of  sore-throat; 

Frequent  attacks  of  tonsillitis; 

Thick  voice; 

Offensive  breath; 

Rheumatism  (often  associated  with  diseased  tonsils). 

Summary 

(1)  The  germs  of  many  serious  infectious  diseases 
make  their  way  into  the  body  by  way  of  the  nose  and 


218    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

throat.  If  the  tissues  of  these  passages  are  unhealthy 
the  resistance  to  such  diseases  is  reduced. 

(2)  Obstructions  of  the  nose,  causing  mouth-breath- 
ing, interfere  with  the  important  processes  of  filtering, 
warming,  and  humidification  of  the  inspired  air  in  its 
passage  to  the  lungs. 

(3)  A  healthy  nose  and  throat  are  necessary  for 
normal  speech  and  for  effective  instruction  in  modern 
language. 

(4)  Defects  of  nose  and  throat  are  responsible  for 
a  large  majority  of  the  cases  of  deafness  and  partial 
deafness. 

(5)  Chronic  inability  to  breathe  through  the  nose 
sometimes  results  in  mental  torpor,  defective  growth, 
dental  caries,  and  general  low  vitality.   The  influence 
of  adenoids  in  causing  feeble-mindedness,  however,  has 
probably  been  exaggerated. 

(6)  The  mechanism  by  which  adenoids  and  en- 
larged tonsils  produce  their  injurious  effects  is  not 
sufficiently  known. 

(7)  Tonsils  which  are  badly  enlarged,  or  which  are 
subject  to  frequent  inflammation  (tonsillitis),  nearly 
always  require  removal. 

(8)  Adenoids  which  are  large  enough  to  interfere  in 
any  degree  with  nasal  breathing,  or  which  show  anjr 
tendency  to  cause  inflammation  of  the  eustachian  tube 
or  the  middle  ear,  should  always  be  removed. 

(9)  Removal  should  take  place  early,  usually  by 
the  sixth  year,  and  sometimes  much  earlier. 

(10)  The  preventability  of  adenoids  and  diseased 


THE  NOSE  AND  THROAT  319 

tonsils  is  a  question  which  has  not  been  sufficiently 
investigated. 

(11)  Teachers  should  be  thoroughly  familiar  with  the 
common  symptoms  of  nose  and  throat  disorders  and 
with  their  results.  They  should  instruct  children  from 
the  earliest  grades  in  the  importance  of  unobstructed 
nasal  breathing. 

(12)  The  number  of  school  children  in  the  United 
States  suffering  from  obstructed  breathing  is  at  least 
two  million.  The  educational  and  hygienic  treatment 
of  these  unfortunates  is  a  matter  of  great  national 
concern. 

REFERENCES 

*1.  W.H.  Burnham:  "The  Hygiene  of  the  Nose."  Fed.  Sem.,  1908, 

pp.  155-69. 
*2.  W.  S.  Cornell:  Health  and  Medical  Inspection  of  School  Children. 

1912,  pp.  244-89. 

8.  E.  A.  Crockett:  "Diseases  of  Nose  and  Throat  of  Interest  to 
Teachers."  Proc.  N.E.A.,  1903,  pp.  1028-31. 

4.  E.  Erdely:  "Sind  die  adenoiden  Wucherungen  angeboren?" 
Jahrb.f.  Kinderheilkunde,  1911,  pp.  611-29. 

5.  C.  A.  Dighton :  A  Manual  of  Diseases  of  the  Naso-  Pharynx  ; 
With  Special  Reference  to  the  Part  played  by  them  in  Diseases 
of  the  Ear.  London,  1912,  pp.  168. 

6.  H.  Gutzmann:  "Ueber  Horen  u.  Verstehen."    Zt.  f.  Ange. 
Psych,  u.  psyc.  Sammelforschung,  1908,  pp.  483-503. 

7.  H.  Hagelin:  "Adenoids  and  Modern  Language  Instruction." 
Mod.  Lang.  Teaching,  vol.  iv,  pp.  16-19  and  38-44. 

*8.  R.  Kafemann:  "Ueber  d.  Beinflussung  geistiger  Leistungen 
durch  Behinderung  der  Nasenatmung."  Psych.  Arbeiten,  1904, 
pp.  435-53. 

9.  M.  Laaser:  "Einige  Schulhygienische  Betrachtungen."   Zt.  f. 
Schulges.,  1898,  pp.  365-72. 

*10.  Dr.  Mouton :  "  Die  Aprosechsia  Nasalis  dei  Schulkindern."  Zt.  f. 

Schulges.,  1903,  pp.  71-80. 
*11.  H.  J.  Mulford:  "The  Throat  of  the  Child."  Ed.  Rev.,  1897,  pp. 

261-72. 

12.  F.  J.  Poynton:  "The  Prevention  of  Rheumatism  hi  Childhood.'* 
School  Hygiene,  1912,  pp.  131-42. 

13.  G.  E.  Schweinitz  and  A.  B.  Randall:  An  American  Textbook  oj 
Diseases  of  the  Eye,  Ear,  Nose,  and  Throat.  1906,  parts  3  and  4. 


220    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

(See  especially  articles  by  Freeman,  Bryan,  Asch,  Wright, 
Newcomb,  and  Leland.) 

*14.  Macleod  Yearsley : "  Occurrence  of  Adenoids  in  London  County 
Council  Schools."  Journal  of  Children's  Diseases,  February 
and  March,  1910. 

See  also  standard  texts  on  school  hygiene,  medical  inspection  of 
schools,  and  children's  diseases.   . 


CHAPTER  XIII 

DEFECTS  OF  HEARING  AND  THE  HYGIENE  OF  THE  EAB 
Written  with  the  assistance  of  Dr.  E.  B.  Hoag 

The  prevalence  of  defective  hearing 

STUDIES  of  defective  hearing  among  school  children 
have  given  extremely  large  differences  as  regards  the 
proportion  affected.  Some  investigators  report  as  few 
as  1  per  cent;  others  as  many  as  50  per  cent.  This  wide 
range  in  the  statistics  does  not  indicate  any  corres- 
ponding range  in  the  actual  prevalence  of  the  defect, 
but  is  due  mainly  to  the  lack  of  a  uniform  standard  as 
to  what  constitutes  "defective  hearing"  and  to  lack  of 
uniformity  in  methods  of  testing. 

It  is  only  for  sake  of  convenience  that  we  are  justi- 
fied in  rigidly  classifying  individuals  as  having  either 
"defective  hearing"  or  "normal  hearing."  The  most 
careful  tests  show  that  there  is  no  plain  demarcation 
between  the  two  classes.  Normal  hearing  is  simply 
that  degree  of  auditory  acuity  found  in  the  majority 
of  individuals.  This  shades  off  gradually  into  subnor- 
mal hearing  on  the  one  han  i,  and  into  superior  hearing 
on  the  other.  The  farther  we  get  away  from  the  aver- 
age in  either  direction,  the  smaller  the  number  of  cases 
represented.  Because  of  the  influence  of  disease,  the 
number  of  cases  with  defective  hearing  is  much  greater 
than  the  number  with  above-normal  hearing. 


222    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


With  the  above  explanation,  such  differences  as 
appear  in  the  following  statistics  ought  not  to  be  mis- 
leading. A  low  figure  means  that  only  severe  degrees 
of  the  defect  have  been  reported;  a  high  figure  means 
that  minor  defects  also  have  entered  into  the  results. 

TABLE   25 


Investigator 

Place 

No.  of  Children 

Per  cent 
reported 
defective 

Reichard 

Riga 

1055 

22.27 

Weil 

Stuttgart 

5905 

31.22 

Gellfi 

Paris 

1400 

20  to  £5 

Moure 

Bordeaux 

3588 

17.15 

Bezold 

Munich 

1918 

25.8 

Zhennunsky 

St.  Petersburg 

3577 

13  to  16 

Cheattle 

London 

1000 

50 

Felix 

France 

1038 

81 

Laubi 

Switzerland 

2200 

10.6 

Smedley 

Chicago 

5760 

23. 

Newmayer 

Philadelphia 

(  3587  "exempt" 
I  1418  "non-exempt" 

1. 

2. 

Bryan 

Camden,  N.  J. 

j  8110  normal  age 
}  2020  retards 

4. 

6. 

Medical 

New  York  City 

266,426 

.5 

examiners 

Medical 

Five  East-End 

1006 

7.2 

examiners 

Schools  of  London 

The  above  results  were  secured  by  a  great  variety  of 
methods  and  standards.  The  report  covering  the  great- 
est number  of  children,  and  one  of  the  least  valuable, 
is  that  from  New  York.  In  that  city,  evidently,  a 
pupil  has  to  be  practically  deaf  in  order  to  be  con- 
sidered defective  in  hearing.  Among  the  most  careful 
tests  yet  made  are  those  of  McCallie  in  Philadelphia 
and  Reik  hi  Baltimore.  McCallie  tested  560  ears 
and  found  14  per  cent  "slightly  deaf"  and  2  per  cent 


DEFECTS  OF  HEARING  223 

"quite  deaf."  Reik  reports  10  per  cent  of  440  children 
as  having  defective  hearing. 

We  may  safely  conclude,  therefore,  that  from  10  to 
20  per  cent  of  school  children  do  not  hear  normally  and 
that  the  hearing  of  from  2  to  5  per  cent  is  very  seriously 
impaired.  Sex  and  age  differences  are  very  slight, 
practically  non-existent. 

The  number  of  persons  who  are  entirely  deaf  is 
usually  given  as  about  700  per  million.  This  would  be 
about  60,000  in  the  United  States.  However,  if  the 
rate  for  Germany  can  be  accepted  for  this  country,  our 
deaf  must  number  not  far  from  75,000.  About  half  of 
this  is  acquired;  the  rest  hereditary. 

The  importance  of  normal  hearing  for  mental 
development 

Hearing  ranks  in  importance  with  vision  as  an 
Avenue  for  the  acquisition  of  knowledge.  In  certain 
respects,  deafness  is  more  damaging  to  mental  devel- 
opment than  blindness.  Although  the  blind  child,  un- 
educated, may  grow  up  very  ignorant,  he  seldom  gives 
the  impression  of  being  mentally  defective.  The  un- 
educated deaf  child,  on  the  other  hand,  nearly  always 
appears  stupid.  So  true  is  this  that  deafness  was  for- 
merly believed  to  be  always  associated  with  disease  or 
deficiency  of  the  central  nervous  system.  School  chil- 
dren who  hear  poorly  are  always  in  danger  of  being 
mistaken  by  their  teachers  for  dullards. 

This  is  readily  understood  when  we  stop  to  consider 
the  role  of  hearing  in  everyday  life.  Deprived  of  this 


224    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

sense,  even  in  part,  the  child  suffers  inevitable  handi- 
caps. Language  development  is  stunted  because  speech 
is  imperfectly  understood;  and  language  is  the  main 
vehicle  of  mental  progress.  The  earning  power  may 
be  reduced  50  per  cent.  The  social  instincts  may  be 
starved  or  perverted  because  normal  intercourse  with 
other  children  is  impossible.  Partially  deaf  children 
are  apt  to  be  considered  "queer."  Deprived  of  the 
healthful  and  educative  influence  of  cooperative  play, 
such  children  often  fail  to  develop  normally  either  in 
body  or  character.  Misunderstood  and  misjudged  on 
every  hand,  they  are  likely  to  harbor  silent  resentment 
or  to  develop  traits  of  irritability,  stubbornness,  and 
the  like. 

That  serious  defects  of  hearing  tend  to  produce 
school  retardation  has  been  fully  demonstrated.  The 
proportion  of  partially  deaf  children  in  the  schools  of 
Camden,  New  Jersey,  was  found  to  be  50  per  cent 
greater  among  the  retarded  than  among  those  who 
were  up  to  grade.  Newmayer's  study  of  5005  Phila- 
delphia children  showed  that  the  3587  who  were  ex- 
cused from  final  examinations  on  the  basis  of  good 
work  had  defects  of  hearing  only  half  as  frequently  as 
the  1418  non-exempt.  Barr  asked  Glasgow  teachers 
to  pick  out  70  "very  bright"  and  70  "very  dull" 
children.  Examination  of  these  revealed  that  4  of  the 
former  and  10  of  the  latter  were  defective  in  both  ears, 
while  10  of  the  former  and  15  of  the  latter  were  defec- 
tive in  one  ear.  Permewan  had  203  pupils  in  Liverpool 
classified  by  their  teachers  as  "bright,"  "average,"  or 


DEFECTS  OF  HEARING  225 

"dull,"  and  found  that  the  average  distance  for  hear- 
ing a  watch  tick  was  51  feet,  47  feet,  and  31  feet  for  the 
three  classes  respectively.  Of  20  pupils  reported  as 
"poorest"  in  a  school  of  Paris,  Gelle  found  only  4  with 
normal  hearing.  Zhermunsky,  at  St.  Petersburg,  found 
24  per  cent  of  the  pupils  with  normal  hearing  were 
classed  by  their  teachers  as  "poor"  in  school  work, 
while  the  proportion  of  "poor"  among  those  whose 
hearing  was  less  than  one  third  normal  was  58  per  cent. 
The  percentage  of  partially  deaf  among  1000  London 
children  was  as  follows:  — 

Worst  mentality 34f  per  cent 

Poor  mentality 27 

Fair  mentality 33i 

Good  mentality 31 

Excellent  mentality 22 

The  figures  just  quoted  indicate  that  although  par- 
tially deaf  children  are  not  always  retarded,  they  are 
more  likely  to  become  so  than  children  with  normal 
hearing.  Among  the  very  dull,  especially,  the  propor- 
tion of  partially  deaf  is  abnormally  high.  Likewise  the 
proportion  of  retarded  children  among  the  very  deaf  is 
also  extremely  high.  Thus  Kobrak,  testing  400  chil- 
dren of  Breslau  shortly  after  school  entrance,  discovered 
six  whose  hearing  was  less  than  one  twentieth  normal. 
Five  of  these  were  considered  stupid  by  their  teachers. 
Of  205  pupils  of  the  Berlin  Hilfsschulklassen  (classes 
for  the  mentally  defective),  20  per  cent  had  less  than 
one  third  normal  hearing  and  8  per  cent  less  than  one 
twentieth.  Wanner  found  12  out  of  39  children  in  the 


226    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

Munich  Hilf sschulklassen  with  less  than  one  twentieth 
normal  hearing  (quoted  by  Kobrak). 

One  reason  for  the  correlation  between  deafness  and 
retardation  lies  in  the  fact  that  a  very  large  proportion 
of  those  with  defective  hearing  are  "adenoid  children," 
and  are  for  this  reason  mentally  sluggish.  But  that  the 
stupidity  of  the  deaf  is  often  apparent  rather  than  real 
is  shown  by  Kobrak's  study  of  677  children  in  the 
Hilfsschulklassen  of  Berlin.  It  was  found  that  in  these 
classes,  where  the  pupils  are  given  a  large  amount  of 
individual  attention  and  are  instructed  by  teachers  of 
special  training,  the  partially  deaf  were  making  on  an 
average  better  progress  than  those  with  normal  hearing. 
The  explanation  is  not  that  deafness  is  an  advantage, 
but  that  many  of  these  children  in  the  classes  for 
mentally  defectives  were  there  because  they  could  not 
hear  well  and  not  because  of  defective  mentality. 

The  hearing  of  the  deaf  child  is  by  no  means  uni- 
form, but  varies  according  to  the  condition  of  the 
weather,  the  state  of  the  throat,  etc.  On  some  days  it 
is  almost  normal ;  at  other  times  extremely  poor.  This 
results  in  what  appears  to  be  an  unevenness  of  atten- 
tion and  response;  hence  the  child  is  likely  to  be  scolded 
or  otherwise  unjustly  treated. 

Another  result  of  defective  hearing  is  overstrain  of 
attention  and  mental  fatigue.  In  order  to  realize  how 
serious  this  may  be,  one  has  only  to  recall  the  feelings 
of  strain  and  exhaustion  experienced  after  an  hour  or 
two  spent  in  listening  to  a  public  speaker  whose  voice 
was  hardly  audible. 


DEFECTS  OF  HEARING  227 

Discharging  ears 

The  discharging  ear  presents  a  very  serious  condi- 
tion. If  it  is  not  treated  until  cured,  the  result  is  very 
likely  to  be  either  partial  or  total  deafness.  In  many 
cases  the  infection  spreads  to  the  surrounding  bone 
and  necessitates  a  dangerous  surgical  operation.  Some- 
times death  results.  To  have  chronic  discharge  of  the 
ear  is  like  living  over  a  powder  mine.  The  explosion 
may  not  come,  but  there  is  always  a  dangerous  pos- 
sibility. Life-insurance  companies  reject  applicants 
with  chronic  ear-discharge.  Death  from  this  cause 
often  results  in  middle  life,  or  after,  and  in  such  cases 
the  condition  usually  dates  back  to  childhood. 

Severe  defects  of  hearing  are  due  to  neglected  inflam- 
mation of  the  middle  ear  of tener  than  to  anything  else. 
The  condition  is  one  which  requires  long-continued 
treatment.  Skillfully  treated,  discharging  ear  is  almost 
always  curable;  neglected,  it  remains  indefinitely  as  a 
menace  to  the  sense  of  hearing  and  to  life  itself. 

It  needs  to  be  clearly  understood  that  the  suppurat- 
ing middle  ear  is  not  primarily  a  disease  of  the  ear,  but 
(almost  always)  an  infection  which  has  spread  from  the 
nose  or  pharynx.  The  infection  may  also  spread  to  the 
openings  in  the  mastoid  bone,  which  are  in  reality  con- 
tinuations of  the  cavity  of  the  middle  ear,  and  there 
cause  grave  danger  to  life.  It  is  to  relieve  this  condi- 
tion that  the  "mastoid  operation"  is  performed. 

Medical  inspection  reveals  that  an  average  of  some 
2  per  cent  of  school  children  have  ear-discharge,  and 
the  total  number,  counting  those  who  have  had  the 


228    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

defect  and  recovered  from  it,  amounts  to  8  or  10  per 
cent.  Denker  found  about  1  per  cent  of  secondary- 
school  pupils  and  2  per  cent  of  elementary  pupils  in 
Germany  with  present  ear-discharge.  The  number  who 
had  had  the  defect  at  some  time  was  approximately  12 
per  cent  (9).  Of  1006  poor  children  in  three  average 
East-End  Schools  of  London,  7.3  per  cent  had  present 
ear-discharge  and  13.4  per  cent  additional  showed 
symptoms  (cicatrices)  of  previous  discharge.  Dr.  E.  B. 
Hoag  finds  that  from  2  to  3  per  cent  have  chronic  ear- 
suppuration.  Cornell  places  the  number  at  1  to  2  per 
cent.  The  proportion  is  usually  smaller  with  older 
children  than  with  younger,  due  probably  to  the  bet- 
ter habits  of  cleanliness  among  older  children  and 
to  the  fact  that  their  adenoids  and  enlarged  tonsils 
have  often  had  the  necessary  surgical  attention.  The 
greater  cleanliness  of  older  children  also  doubtless  con- 
ceals a  good  many  cases  of  the  defect.  On  the  whole, 
Burnham's  estimate  of  2  percent  does  not  seem  exces- 
sive. This  is  not  far  from  one  case  for  each  schoolroom, 
or  a  total  of  nearly  a  half-million  in  the  schools  of  the 
United  States. 

The  causes  of  ear  defects 

Apart  from  congenital  deafness,  which  is  nearly 
always  due  to  heredity,  defects  of  hearing  have  three 
main  causes:  (1)  diseased  conditions  of  the  nose  and 
throat;  (2)  infectious  diseases;  and  (3)  stoppage  of  the 
outer  canal. 

The  first-named  cause  is  by  far  the  most  important, 


DEFECTS  OF  HEARING  229 

accounting  for  considerably  more  than  half  of  all  cases.1 
The  conditions  of  nose  and  throat  most  frequently 
involved  are  adenoids,  enlarged  tonsils,  and  chronic 
catarrh.  Most  cases  of  acquired  deafness  in  children 
are  due,  directly  or  indirectly,  to  diseased  conditions  of 
the  nose  or  throat.  Neglected  colds,  adenoids,  chronic 
catarrhal  conditions,  and  infectious  diseases  which 
affect  the  throat  (measles,  scarlet  fever,  and  diph- 
theria) are  the  chief  culprits. 

It  will  be  remembered  that  the  middle  ear  is  con- 
nected with  the  pharynx  by  the  eustachian  tube,  and 
that  the  mucous  membrane  of  the  middle  ear  is  contin- 
uous with  that  of  the  eustachian  tube  and  pharynx. 
In  childhood  the  eustachian  tube  is  relatively  short, 
wide,  and  straight,  making  an  easy  road  over  which 
disease  germs  may  travel  from  the  throat  to  the  middle 
ear.  Inflammation  of  the  throat,  such  as  is  present  in 
colds,  catarrh,  or  disease  of  the  tonsils,  sometimes 
causes  swelling  of  the  walls  of  the  eustachian  tube  and 
interferes  with  the  ventilation  and  drainage  of  the 
middle  ear. 

Normally,  the  mucus  which  is  constantly  being 
secreted  by  the  membrane  lining  the  middle  ear  is 
propelled  through  the  eustachian  tube  by  the  wave 
action  of  the  cilia.  Disease  of  the  mucous  membrane, 
as  in  catarrh  and  the  like,  interferes  with  the  action 
of  the  cilia  and  prevents  drainage.  When  this  occurs, 
two  results  are  likely  to  follow:  (1)  the  mucus  of  the 

1  Holmes  says  60  per  cent;  Zhermunsky,  64  per  cent;  Burkner, 
83  to  60  per  cent;  Cornell,  95  per  cent;  and  Love,  "nearly  all." 


230    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

middle  ear  (perhaps  containing  pathogenic  bacteria)  ac- 
cumulates for  lack  of  normal  drainage  to  the  pharynx; 
and  (2)  the  atmospheric  pressure  on  the  two  sides  of 
the  eardrum  becomes  unequal  and  may  cause  a  rupture. 
The  accumulated  pus  then  escapes  through  the  outer 
canal  and  we  have  what  is  called  the  "suppurating 
ear." 

By  early  and  thorough  treatment  of  running  ears 
many  cases  of  deafness  will  be  prevented.  There  is  on 
an  average  about  one  case  of  ear-discharge  in  each 
schoolroom.  The  presence  of  cotton  in  the  ear  ought 
to  excite  the  teacher's  suspicion.  Earache,  although  it 
may  have  other  causes,  is  usually  associated  with  acute 
inflammation  of  the  middle  ear.  An  aching  ear  is  a 
signal  of  trouble;  a  discharging  ear  is  a  sign  that  the 
trouble  has  already  occurred ;  a  neglected  discharging 
ear  is  a  sign  of  progressive  deafness. 

As  already  pointed  out  (chapter  xii),  defective 
hearing  is  one  of  the  commonest  symptoms  of  adenoids. 
Deaf  children  are  therefore  extremely  likely  to  be 
mouth-breathers.  Yearsley's  report  of  1006  children  in 
London  showed  mouth-breathing  one  third  more  fre- 
quent among  the  partially  deaf  than  among  those  with 
normal  hearing. 

The  next  most  common  cause  of  defective  hearing 
is  acute  infectious  diseases,  principally  scarlet  fever, 
measles,  and  diphtheria.  These  probably  account  for 
10  to  20  per  cent  of  all  cases.  In  measles  and  scarlet 
fever  the  middle  ear  is  nearly  always  affected  to  greater 
or  less  degree.  Of  500  totally  deaf  persons  studied  by 


DEFECTS  OF  HEARING  281 

Holmes,  36  cases  were  the  result  of  measles.  For  years 
the  writer  has  made  it  a  practice  in  hygiene  classes  to 
ask  the  students  how  many  know  an  individual  who 
has  defective  hearing  from  this  cause.  There  are  few 
students  who  cannot  name  at  least  one  such  case. 
Children  recovering  from  acute  infectious  diseases 
should  be  closely  watched.  Deafness,  mastoid  opera- 
tions, and  the  like  are  complications  which  should 
never  be  allowed  to  arise. 

It  should  also  be  emphasized  that  running  ear  fol- 
lowing an  infectious  disease  is  always  a  source  of  danger 
to  others,  as  the  discharge  may  contain  the  germs  of 
the  disease  in  question.  Epidemics  of  scarlet  fever, 
measles,  and  diphtheria  are  believed  to  originate  some- 
times in  this  way. 

Accumulation  of  wax  in  the  outer  canal  sometimes 
takes  place,  but  this  cause  is  responsible  for  only  a 
small  percentage  of  cases.  The  accumulation  is  some- 
times the  result  of  a  diseased  condition  of  the  outer 
canal  causing  profuse  secretion  and  incomplete  re- 
moval of  the  wax.  Sometimes  it  is  caused  by  pushing 
the  wax  against  the  eardrum  in  the  effort  to  remove  it 
with  a  pencil,  hairpin,  or  damp  cloth.  Wax  accumula- 
tions can  be  safely  removed  only  by  the  physician. 

Contrary  to  popular  opinion,  accidents  to  the  ear- 
drum do  not  ordinarily  produce  serious  results  unless 
the  entire  structure  is  destroyed.  This  is  because  the 
drum  is  endowed  with  such  a  remarkable  growth  power 
that  the  slight  puncture,  or  rent,  is  quickly  repaired. 
Complete  recovery,  in  fact,  may  occur  within  a  few 


232    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

hours.  About  25  per  cent  of  all  adults  have  had  a 
puncture  of  the  eardrum.  Even  the  total  loss  of  the 
eardrum  does  not  destroy  hearing,  though  of  course  it 
greatly  reduces  it.  One  serious  danger  to  the  middle 
ear  from  loss  of  the  eardrum  is  the  increased  danger  of 
infection  from  without.  In  such  cases  there  is  nothing 
to  block  the  entrance  of  disease  germs. 
Summarizing,  we  may  say :  — 

(1)  Deafness  nearly  always  has  its  origin  in  child- 
hood. 

(2)  In  the  vast  majority  of  cases  it  is  due  to  diseased 
conditions  of  the  nose  or  throat,  and  is  therefore  usu- 
ally preventable. 

(3)  The  source  of  the  trouble  may  be  either  (a) 
some  chronic  disorder  of  the  throat,  such  as  adenoids, 
enlarged  tonsils,  catarrh,  etc.,  or  (6)  an  acute  infec- 
tious disease  which  involves  the  throat,  usually  scar- 
let fever,  measles,  or  diphtheria. 

(4)  Wax  accumulations  and  injuries  to  the  drum  are 
occasional  but  not  very  frequent  causes. 

The  function  of  the  school 

We  have  found  that  from  10  to  20  per  cent  of  school 
children  have  defects  of  hearing.  One  fourth  of  these 
cases,  at  least,  are  very  serious.  A  considerable  num- 
ber are  in  danger  of  becoming  entirely  deaf;  in  other 
cases  life  itself  is  jeopardized.  Instruction  is  rendered 
difficult,  retardation  may  occur,  and  even  the  charac- 
ter of  the  child  may  be  unfavorably  influenced  by  the 
defect. 


DEFECTS  OF  HEARING  233 

It  is  well  attested  that  nearly  all  cases  of  acquired 
deafness  have  their  origin  in  childhood  and  that  a  large 
majority  are  preventable.  Estimates  of  the  proportion 
preventable  range  from  50  to  80  per  cent.  Theoreti- 
cally, at  least,  all  the  deafness  due  to  acute  infectious 
disease  and  to  chronic  nose  and  throat  troubles  (the 
two  main  causes)  are  preventable. 

It  is  evident,  therefore,  that  if  we  would  prevent 
deafness  the  children  are  the  only  rational  point  of  at- 
tack. The  question  that  remains  is  merely  how  best 
to  reach  them. 

There  are  only  two  institutions  through  which  this 
may  be  done :  the  school  and  the  home.  If  all  parents 
were  sufficiently  intelligent  to  discover  the  defect,  wise 
enough  to  appreciate  its  importance,  and  wealthy 
enough  to  secure  the  needed  treatment,  the  function 
of  the  school  would  then  be  merely  the  negative  one  of 
avoiding  injury  to  the  child's  ears.  The  facts,  how- 
ever, are  the  reverse  of  this.  Parents  very  rarely  dis- 
cover the  defect  unless  hearing  is  reduced  as  low  as  one 
third  to  one  fourth  the  normal.  They  simply  scold  the 
child  as  listless  or  perverse.  Other  parents,  aware  of 
the  defect,  neglect  it  either  from  underestimation  of 
its  seriousness  or  from  poverty.  The  school  must 
undertake  the  work  because  it  is  the  sole  remaining 
agency. 

The  school's  first  duty  is  to  ascertain  what  children 
have  imperfect  hearing.  The  teacher  cannot  be  de- 
pended upon  to  do  this  by  mere  observation  any  more 
than  the  parent.  She,  too,  overlooks  the  defect  and 


234    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

blames  the  child  for  inattention  or  regards  him  as 
stupid.  Tests  of  hearing  are  necessary,  and  should  be 
given  to  all  the  school  children  each  year.  The  test 
given  when  the  child  enters  school  is  especially  import- 
ant. 

When  defective  hearing  has  been  discovered,  its 
cause  should  be  ascertained.  This  can  often  be  done 
by  the  regular  school  physician,  but  in  very  many 
cases  an  examination  by  a  specialist  is  necessary.  Ear, 
nose,  and  throat  specialists  should  be  employed  by  the 
school  for  this  purpose.  When  this  is  not  done,  much 
follow-up  work  will  generally  be  required  in  order  to 
persuade  parents  to  seek  the  right  kind  of  medical 
advice. 

The  next  step  is  to  secure  the  needed  treatment. 
If  adenoids  are  present,  they  should  be  removed. 
Enlarged  tonsils  and  chronic  catarrh  should  receive 
appropriate  treatment.  If  the  ear  is  discharging  it  must 
be  cleansed  and  treated,  usually  for  months. 

The  present  methods  for  dealing  with  the  latter  evil 
are  utterly  inadequate.  As  a  rule,  parents  lack  the 
knowledge  of  hygiene  and  medicine  which  would  en- 
able them  to  appreciate  the  situation.  Others,  and 
these  are  very  numerous,  cannot  afford  the  service  of 
specialists  at  current  rates  and  are  reluctant  to  accept 
as  a  charity  what  they  have  not  means  to  command. 
Even  when  a  specialist  is  consulted,  the  tedious  treat- 
ment which  ensues  (cleansing,  syringing,  etc.)  is  sel- 
dom carried  out  with  the  needed  regularity  and  care. 
Physicians  find  that  in  most  cases  it  is  simply  folly  to 


DEFECTS  OF  HEARING  235 

expect  a  cure  by  this  method.  The  only  assurance  of 
success  in  this  direction  is  for  the  child  to  be  taken 
several  times  a  week  to  the  physician's  office  or  to  the 
hospital  for  the  necessary  treatment.  Aside  from  the 
question  of  expense,  it  is  useless  to  expect  that  this  will 
'  be  done.  Treatment  is  almost  sure  to  be  intermittent 
and  to  be  discontinued  too  early.  Each  visit  to  the 
hospital  may  consume  hours  of  time.  Whether  rich  or 
poor,  we  are  too  busy  and  impatient  to  submit  to  such 
a  tedious  ordeal.  The  result  is  that  nine  tenths  of 
the  cases  of  ear-discharge  among  school  children  have 
been  and  are  still  being  neglected. 

The  only  solution  of  the  problem  lies  in  the  installa- 
tion of  the  school  medical  clinic  for  free  treatment. 
This  is  England's  solution,  and  it  is  the  ideal  one.1  The 
child  goes  as  often  as  necessary  to  the  near-by  clinic, 
and  receives  the  necessary  treatment  at  the  hands  of  a 
nurse  or  doctor.  There  is  little  waste  of  time,  no  loss  of 
school  attendance,  and  a  mere  bagatelle  of  expense. 
Even  this  is  borne  by  the  city.  Best  of  all,  the  treat- 
ment brings  cure.  The  only  objection  is  the  fetish  of 
"parental  responsibility." 

But  theorize  as  we  may  about  the  danger  of  tamper- 
ing with  parental  responsibility,  we  are  confronted  by 
this  fact  of  neglect.  The  rights  of  children  to  health 
and  happiness  surely  outweigh  any  possible  danger  the 
scheme  involves  to  the  parents'  sense  of  responsibility. 
It  is  not  a  very  lofty  system  of  ethics  which  would  per- 

1  By  1913,  ninety-five  educational  authorities  in  England  had  ea 
tablished  clinics  for  the  free  use  of  school  children. 


236    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

mit  children  to  become  deaf  as  a  moral  lesson  to  their 
parents! 

Teachers  and  school  nurses,  as  well  as  the  medical 
inspector,  should  keep  a  sharp  lookout  for  ear  troubles. 
Children  who  return  to  school  after  an  attack  of 
measles,  scarlet  fever,  or  diphtheria  need  to  be  watched, 
and  the  first  signs  of  earache  or  "thickness  of  hearing" 
should  arouse  suspicion.  The  same  is  true  of  children 
who  are  subject  to  chronic  nose  or  throat  trouble,  who 
catch  colds  easily,  etc.  It  is  well  for  teachers  to  remem- 
ber that  the  child  who  has  earache  may  be  in  danger  of 
deafness.  Follow-up  work  to  secure  the  removal  of  ade- 
noids and  the  treatment  of  throat  disorders  cannot  be 
too  vigorously  prosecuted. 

The  school  itself  can  accomplish  something  by  pro- 
tecting the  child  from  taking  cold.  Overheated  and 
dusty  schoolrooms,  deprivation  of  physical  activity, 
and  the  like  predispose  to  just  those  conditions  of  nose 
and  throat  which  give  rise  to  so  many  cases  of  ear 
complication. 

Children  should  be  taught  how  to  care  for  the  ear, 
how  to  wash  it  without  risk  of  pushing  the  wax  back 
against  the  drum,  not  to  probe  into  it,  not  to  box  the 
ear,  pull  it,  blow  into  it,  etc. 

The  teacher's  voice  should  have  sufficient  force  and 
carrying  power  to  be  heard  without  strain  of  attention 
in  the  rear  of  the  room.  Purity  of  tone  and  modula- 
tion, rather  than  loudness,  are  the  essential  qualities. 
The  shrill  voice  is  as  objectionable  for  its  poor  acoustic 
properties  as  for  its  disagreeableness.  Normal  schools 


DEFECTS  OF  HEARING  237 

could  well  afford  to  substitute  lessons  in  voice  culture 
for  some  of  their  work  in  formal  grammar.  Classrooms 
should  be  built  with  proper  proportions  (not  far  from 
24  X  28  feet),  and  should  be  located  where  outside 
noises  will  not  disturb. 

Directions  for  testing  hearing 

The  expensive  apparatus  and  complicated  proce- 
dures sometimes  employed  for  testing  auditory  acuity 
are  not  in  the  least  necessary  for  ordinary  school  pur- 
poses. With  a  little  care  any  teacher  can  make  a  suffi- 
ciently accurate  test  of  a  child's  hearing  hi  from  three 
to  five  minutes.  Either  the  "watch"  method  or  the 
"whisper"  method  may  be  used.  Each  has  its  advan- 
tages and  disadvantages,  but  on  the  whole  the  latter  is 
perhaps  somewhat  more  satisfactory. 

For  the  whisper  test  a  room  at  least  twenty-five  or 
thirty  feet  long  is  necessary.  At  this  distance  a  rather 
low  whisper  is  easily  audible  to  persons  of  normal  hear- 
ing. The  pupils  should  be  tested  singly.  The  child  to 
be  tested  should  be  placed  in  a  chair  at  one  end  of  the 
room  with  one  ear  toward  the  teacher.  The  other  ear 
must  be  closed  tightly  with  a  rubber  stopper  or  with 
clean  cotton.  If  a  stopper  is  used,  it  should  either  be 
disinfected  for  each  child  or  replaced  by  a  new  one.  If 
cotton  is  used,  it  should  be  rolled  into  a  rather  firm 
ball  so  that  in  removal  remnants  will  not  be  detached 
and  left  in  the  canal. 

The  examiner  should  stand  at  the  other  end  of  the 
room  and  prorounce  in  a  whisper  of  uniform  loudness  a 


238    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

list  of  words.  Numerals  chosen  at  random  from  1  to 
100  are  suitable.  The  distance  of  the  examiner  should 
remain  the  same  throughout  the  test,  the  acuity  of 
hearing  being  represented  by  the  percentage  of  whis- 
pers heard.  If  a  majority  of  the  children  of  a  class  can 
hear,  for  example,  10  out  of  a  list  of  20  whispered 
numerals,  then  10  out  of  20  is  taken  as  the  standard  for 
normality.  The  ear  that  hears  only  5  is  accordingly 
recorded  as  half  normal,  etc. 

This  is  known  as  the  "method  of  constant  range,"  as 
contrasted  with  "the  method  of  extreme  range."  By 
the  latter  method,  the  examiner  moves  from  a  distance 
at  which  the  sound  is  clearly  heard  to  a  point  where  it 
is  no  longer  audible.  The  distance  at  which  the  sound 
entirely  ceases  to  be  heard  is  recorded,  and  the  reverse 
procedure  is  then  followed  out.  That  is,  the  examiner 
begins  at  a  point  where  the  sound  cannot  be  heard  at 
all  and  moves  closer  until  it  is  unmistakably  perceived. 
The  average  of  the  two  records  thus  secured  represents 
the  child's  hearing  range  for  this  particular  stimulus. 

The  method  first  described  is  preferable  because 
it  is  less  likely  than  the  other  to  be  vitiated  by  the 
reflection  of  sound  from  the  walls.  It  does  not,  how- 
ever, enable  us  to  measure  the  hearing  of  children  who 
are  extremely  deaf. 

Whatever  the  method,  and  whether  watch  or  whis- 
per be  employed,  the  standard  is  purely  a  relative  one. 
Different  watches,  likewise  the  whispers  of  different 
people,  vary  much  in  loudness.  Rooms  also  differ  in 
acoustic  properties.  The  teacher  should  take  as  her 


DEFECTS  OF  HEARING  239 

standard  of  normality  the  average  performance  of  a 
majority  of  children  of  a  class.  Those  who  fall  far 
below  this  are  certainly  not  normal,  and  ought  to  be 
examined  by  the  school  doctor  or  by  an  aurist. 

The  tests  should  be  given  to  all  the  children,  not 
simply  to  those  whose  hearing  is  under  suspicion. 
Children  who  are  partly  deaf  become  wonderfully 
adept  at  lip  reading,  guessing  at  meanings  when  only 
fragments  of  speech  are  heard,  parrying  questions, 
and  the  like,  so  that  a  high  degree  of  the  defect  may 
exist  without  exciting  suspicion  in  any  but  a  close 
observer.  It  is  not  meant  that  the  child  consciously 
makes  false  pretenses  of  hearing.  It  is  all  simply  an 
unconscious  adaptation  to  a  condition  whose  presence 
the  child  himself  is  ordinarily  not  aware  of.  The  semi- 
deaf  child  is  not  conscious  of  his  defect  because  he  has 
no  other  standard  of  hearing  than  his  own. 

Special  schools  for  deaf  children 

We  must  recognize  the  right  of  all  children  to  a  free 
education  who  are  able  to  profit  by  it.  This  includes 
children  of  all  degrees  of  deafness.  The  education, 
moreover,  should  be  just  that  kind  from  which  the 
child  in  question  will  derive  the  greatest  benefit. 

The  education  of  deaf-mutes  is  usually  provided  for 
in  state  institutions,  but  thus  far  little  provision  has 
been  made  for  the  large  number  of  children  who  are 
not  entirely  deaf,  but  who  are  yet  too  deaf  to  derive 
the  maximum  profit  from  the  ordinary  class. 

As  Dr.  Love  and  Dr.  Yearsley,  two  noted  English 


240    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

authorities  on  this  question,  have  urged  for  many 
years,  the  most  imperative  need  in  this  field  at  present 
is  for  a  more  scientific  classification  of  deaf  children 
for  educational  purposes.  According  to  Dr.  Love,  who 
has  examined  institutions  for  the  deaf  in  all  parts  of 
Europe  and  America,  a  large  proportion  of  those  who 
are  being  educated  in  these  institutions  do  not  right- 
fully belong  in  schools  for  deaf-mutes.  They  are  the 
children  who  have  a  considerable  remnant  of  hearing 
or  who  became  deaf  several  years  after  they  had  learned 
normal  speech. 

On  the  other  hand,  there  are  many  children  in  the 
regular  classes  of  the  public  schools  who  are  entirely 
too  deaf  to  be  properly  taught  with  normal  children. 
This  group  probably  includes  somewhat  more  than  1 
per  cent  of  the  entire  school  enrollment.  Stewart,1  on 
the  basis  of  12,200  children  examined,  places  it  at  1.16 
per  cent.  Jones,  in  an  investigation  of  3300  children 
for  the  London  County  Council,  reports  1.5  per  cent. 
For  this  type  of  children  special  classes  in  the  public 
schools  are  an  absolute  necessity.  They  should  not  be 
educated  with  deaf-mutes  because  they  need  the  com- 
panionship of  normal  children.  Berlin  has  had  such  a 
class  since  1907  and  London  since  1910.  The  number  of 
children  who  belong  in  such  classes  is  at  least  ten  times 
as  great  as  the  total  number  of  deaf-mutes. 

Deaf-mutes  may  also  be  taught  in  still  other  special 
classes  of  the  day  school,  but  the  residential  school  has 
certain  advantages.  If  the  child's  home  environment  is 
1  Quoted  by  Love. 


DEFECTS  OF  HEARING  241 

good,  the  special  day  school  is  perhaps  better,  for  the 
reason  that  companionship  with  normal  people  favors 
healthy  social  development.  London  has  500  deaf- 
mutes  in  special  day  classes  of  the  public  schools. 

In  whatever  type  of  schools  deaf-mutes  are  educated, 
we  are  not  to  suppose  that  all  of  them  require  exactly 
the  same  kind  of  training.  Normal  children  themselves 
do  not;  and  precisely  because  the  deaf-mute  is  a  deaf- 
mute  and  the  difficulties  of  his  education  therefore 
multiplied  a  hundred  fold,  it  is  so  much  the  more 
important  that  we  base  our  methods  on  medical  and 
psychological  study  of  the  individual  child.  We  refer 
here  especially  to  the  choice  between  the  two  methods 
in  vogue  for  the  instruction  of  the  deaf ;  the  oral  and 
the  manual. 

For  a  half-century  the  champions  of  these  two 
methods  have  waged  bitter  warfare.  It  is  now  pretty 
well  agreed  that  a  majority  of  deaf-mutes  can  learn 
the  oral  method  and  that  they  need  to  do  so.  The 
question  is  chiefly  whether  this  method  should  be  made 
universal.  It  is  so,  practically,  in  Germany.  But  it  is 
well  attested  that  a  considerable  proportion  of  deaf- 
mutes  succeed  indifferently  or  fail  altogether  by  the 
oral  method.  According  to  Love,  some  15  per  cent  of 
deaf-mutes  are  mentally  defective,  and  with  these,  the 
oral  method  is  never  very  successful.  Others,  also, 
succeed  badly  with  it.  It  is  absurd  to  universalize  a 
method  merely  because  it  works  well  in  a  majority  of 
cases. 

The  rule  should  be,  educate  the  deaf  child  in  the 


84*    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

highest  type  of  school  for  which  he  is  fitted.  What  this 
may  be  in  any  particular  case  can  only  be  determined 
by  a  study  of  the  individual  child. 

As  Love  points  out,  the  deaf  and  the  semi-deaf 
should  have  the  advantages  of  a  longer  training  than 
normal  children.  The  school  should  get  them  earlier 
and  keep  them  later.  The  school  period  could  well 
extend  from  3  to  17  years.  The  ideal  pedagogy  for  the 
special  classes  here  advocated  remains  to  be  worked 
out.  If  the  education  of  deaf  and  semi-deaf  children  is 
ever  to  be  placed  on  a  sound  basis,  opportunities  will 
have  to  be  provided  for  the  scientific  training  of  those 
who  teach  them. 

Children  who  are  only  slightly  deaf  can  be  taught  in 
the  same  class  with  normal  children,  but  they  should 
be  given  an  advantage  in  seating.  This  is  a  precaution 
which  no  teacher  can  ignore  without  grave  injustice 
to  the  child  concerned.  In  the  average  group  of  forty 
or  fifty  children  from  one  to  three  will  almost  certainly 
be  found  in  this  group. 

Mention  should  also  be  made  of  psychic  deafness, 
i.e.,  defective  ability  to  interpret  sounds  (usually  speech 
sounds),  without  any  defect  of  the  vocal  organs  them- 
selves. Slight  degrees  of  psychic  deafness  are  by  no 
means  rare,  and  the  defect  is  usually  one  which  re- 
sponds in  a  remarkable  way  to  special  training.  Some- 
times it  is  mistaken  for  true  deafness,  especially  hi 
children  whose  associations  have  been  mainly  with 
deaf-mutes.  The  writer  has  found  one  such  case,  of 
mild  degree,  in  the  seven-year-old  son  of  deaf-mutes. 


DEFECTS  OF  HEARING  243 

This  child,  whose  ears  and  mentality  were  both  nor- 
mal, was  thought  by  his  teachers  to  be  both  mentally 
defective  and  rery  hard-of-hearing. 

Some  indications  of  ear  defects 

Pupil  often  says  "What?" 
Inattention; 
Stupid  appearance; 
Expressionless  voice; 
Poor  spelling; 
Poor  progress  in  general; 
Imperfect  speech; 
Complaint  of  earache; 

Running  ear  (discharge  often  present  without  being  eas- 
ily observed). 

Peculiar  postures  (in  attempt  to  hear). 

Difficult  nasal  breathing  (often  present  with  ear  trouble). 

REFERENCES 

1.  Gustav  Alexander:  "Die  SchulSretliche  Ohrenunterauchung 
an  der  Volksschule  zu  Berndorf  1910-1912."   Zt.  f.  Schulgea., 
1912,  pp.  713-22. 

2.  Fr.  Bezold:  Schuluntersuchungen  uber  das  Kindliche  Hororgan. 
1885.   (Reviewed  by  Chrisman.) 

*3.  Clarence  J.  Blake :  "The  Importance  of  Hearing-Tests  in  Public 

Schools."  Proc.  N.E.A.,  1903,  pp.  1013-19. 
4.  Frank  G.  Bruner :  "The  Hearing  of  Primitive  Peoples."  Colum- 
bia Univ.  Contrib.  to  Phil,  and  Psych.,  vol.  xvii,  no.  3. 
*5.  K.  Braukmann:  "Ueber  die  Bedeutung  des  Gehors  u.  die  Geis- 

tigen  Folgen  seiner  Stonmgen  im  kindlichen  Lebensalter."  Zt. 

f.  Schulges.,  1898,  pp.  129-39. 
*6.  W.  H.  Burnham:  "The  Hygiene  of  the  Ear."    In  Monroe's 

Encyclopedia  of  Education,  1912,  vol.  n. 
*7.  Oscar  Chrisman:  "TheHearing  of  Children."  Ped.  Sem.,  vol.  n, 

1892,  pp.  397-441. 
*8.  W.  S.  Cornell:  The  Health  and  Medical  Supervision  of  School 

Children.   1912,  pp.  290-304. 
*9.  Alfred  Denker:    "Ueber  die  Horfahigkeit  u.   d.   Iliiufigkeit 

des  Vorkommens  von  Inf ectionskrankheiten  im  kindlichen  u. 


244    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

jugendlichen  Alter."    First  International  Congress  for  School 
Hygiene,  1904,  vol.  in,  pp.  230-41. 

10.  K.  V.  Hercsuth: "  Intellectual  and  Moral  Development  of  Deaf- 
Mutes."  Eos,  April,  1911. 

*11.  Kobrak:  "Beziehung  zwischen  Schwachsinn  u.  schwerhb'rig- 

keit."  Zt.  f.  Schulges.,  1908,  pp.  87-97. 

12.  LudwigKotelmann:  School  Hygiene,  1899,  chap.  x.   (Translated 
by  Bergstrom  and  Conradi.) 

*13.  James  Kerr  Love:  The  Deaf  Child.  London,  1911,  pp.  192. 

*14.  James  Kerr  Love:  "The  Educational  Treatment  of  the  Deaf  in 
all  Stages  from  Impaired  Hearing  to  the  Totally  Deaf."  Second 
International  Congress  for  School  Hygiene,  1907,  pp.  828-39. 
15.  D.  P.  MacMillan:  "Some  Results  of  Hearing-Tests  of  Chicago 
School  Children."  Proc.  N.E.A.,  1901,  pp.  876-80. 

>16.  W.  H.  Pyle:  Personal  Hygiene.  1910.   (Chapter  by  B.  A.  Ran- 
dall, "The  Hygiene  of  the  Ear,"  pp.  139-68.) 

17.  F.  H.  Quix:  "Die  Prophylaxe  der  Taubheit  bei  Schulkindern." 
Inter.  Mag.  School  Hygiene,  vol.  vi,  1910,  pp.  422-30. 

18.  Dr.  Reinfelder:  "Schwerhorigkeit  u.  Horschule."  Die  Jugend- 
fiirsorge,  1909,  Heft  3. 

19.  Randall  and  De  Schweinnitz:  American  Textbook  of  Ihe  Dis- 
eases of  Eye,  Ear,  Nose,  and  Throat.    (Especially  articles  by 
Holmes,  Buck,  Wurdemann,  Miller,  etc.) 

>20.  Macleod  Yearsley:  "The  Problem  of  the  Deaf  School  Child." 

Second    International    Congress  for   School  Hygiene,  vol.  in, 

1907,  pp.  839-45. 
*21.  Macleod  Yearsley:  "The  Classification  of  the  Deaf  Child." 

Inter.  Mag.  School  Hygiene,  vol.  vn,  1911,  pp.  4-13. 
f2.  Macleod  Yearsley:  "The  Treatment  of  Suppurating  Ears  in 

School  Children."  School  Hygiene,  vol.  vm,  1912.  pp.  69-78. 


CHAPTER  XIV 

THE  HYGIENE  OP  VISION 
Written  with  the  assistance  of  Dr.  E.  B.  Hoag 

New  demands  upon  the  eye 

EXCEPTING  touch  alone,  the  eye  is  the  most  valued 
of  our  special  senses.  The  conservation  of  vision  has 
been  called  "more  important  than  all  the  work  of  our 
universities."  At  least  one  fourth  of  the  inhabitants  of 
Europe  and  America  are  more  or  less  handicapped  by 
defective  vision.  Since  most  of  the  instruction  given  in 
the  schools  is  based  upon  the  visual  impression,  it  is 
well  to  examine  the  efficiency  of  the  visual  functions  to 
ascertain  the  effects  of  school  work  upon  them. 

Most  of  the  organs  of  the  human  body  were  molded 
in  response  to  definite  demands  of  life  and  environ- 
ment. These  demands  are  the  measures  according  to 
which  nature  has  fashioned  us.  The  eye  is  no  exception 
to  this  law.  Generally  speaking,  each  animal  species 
has  developed  as  good  vision  as  its  mode  of  life  calls  for, 
and  no  better.  "Perfection  for  perfection's  sake"  is 
foreign  to  the  economy  of  nature. 

What  kind  of  an  eye  did  primitive  man  require? 
Plainly,  one  which  would  be  effective  chiefly  for  distant 
seeing,  able  to  make  as  many  as  forty  to  fifty  move- 
ments per  minute,  and  one  which  could  focus  for  a  few 
minutes  on  near  objects,  if  occasion  demanded.  For 


246    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

the  bulk  of  the  human  race,  little  more  than  this  was 
required  of  the  eye  until  the  last  few  hundred  years. 
The  eye  was  permitted,  for  the  most  part,  to  roam  in 
freedom.  It  made  only  large  movements  and  made 
them  slowly.  Fixation  was  rarely  for  more  than  a  few 
seconds.  When  it  tired  of  one  kind  of  work  it  was 
usually  free  to  change  its  activity. 

Quite  recently,  however,  the  eye  has  been  subju- 
gated by  the  tyranny  of  print  and  sentenced  to  a  tread- 
mill form  of  action  for  which  it  was  never  originally 
designed.  In  five  minutes  of  reading  the  eye  makes, 
ordinarily,  over  one  thousand  separated  movements 
and  as  many  fixations,  each  with  "rifle-aim  precision." 
This  is  probably  as  much  work  as  it  was  earlier  re- 
quired to  do  in  one  hour.  The  ciliary  muscle,  in  ac- 
commodating the  eye  for  near  work,  such  as  reading,  ] 
probably  expends  as  much  energy  in  five  minutes  as 
formerly  it  was  necessary  to  expend  in  a  whole  day  of ' 
distant  seeing.  Moreover,  the  accommodation  must 
shift  in  the  reading  of  each  line  as  the  eyes  move  across 
the  page  from  left  to  right,  since  only  in  the  middle  of 
the  line  are  the  two  eyes  equally  near  to  the  point  of 
fixation.  Add  to  these  burdens  the  difficulties  of  too 
fine  print,  insufficient  light,  an  unsuitable  form  of  type, 
improperly  colored  paper,  unhygienic  spacing  of  let- 
ters, lines,  or  words,  and  the  abuse  to  which  the  eye  is 
now  universally  subjected  at  once  becomes  apparent. 

The  few  generations  since  printing  was  invented  have 
not  sufficed  for  the  evolution  of  a  better  eye.  The  new 
work  must  be  done  with  tools  which  were  fashioned 


THE  HYGIENE  OF  VISION  247 

for  other  purposes.  Let  us  see  with  what  success  the 
work  is  done,  with  what  cost  of  effort,  and  with  what 
injury  to  the  tools  themselves. 

The  mechanism  of  vision 

The  eye,  as  every  one  knows,  works  upon  the  princi- 
ple of  the  ordinary  camera.  The  retina  is  the  photo- 
graphic plate,  the  pupil  of  the  eye  is  the  point  of  en- 
trance for  the  rays  of  light,  and  the  crystalline  lens 
corresponds  to  the  lens  of  the  camera.  The  lens,  of 
course,  serves  merely  to  bring  the  rays  of  light  to  » 
locus  on  the  retina  or  photographic  plate. 

In  the  working  of  the  visual  camera  four  possibili- 
ties are  always  present :  — 

(1)  The  distance  from  the  lens  to  the  retina  may  be 
exactly  sufficient  to  permit  rays  of  light  from  distant 
objects  (parallel  rays)  to  be  brought  to  a  focus  upon 
the  retina.  (Fig.  17.) 

This     condition     is    Pr. 

called      "emmetro-      ~ 
pia."     The    emme- 

FIG.  17 

tropic      eye      is      the     Emmetropicornormaleye.  Parallel  rays  focused 
.  on  the  retina 

ideal  eye,  for  it  per- 
mits objects  distant  more  than  a  few  feet  to  be  imaged 
upon  the  retina  with  perfect  distinctness  while  the  eye 
is  at  rest. 

(2)  If  the  distance  from  the  lens  to  the  retina  is  too 
short,  the  parallel  rays  strike  the  retina  before  they 
have  been  brought  to  a  focus,  thus  giving  a  blurred 


248    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


image.  (Fig.  18.)  This  condition  is  "hyperopia,"  or 
"far-sight."  Far-sighted  people,  however,  do  not  see 

even  distant  ob- 
jects clearly  when 
the  eye  is  at  rest; 
though  the  farther 

FIG.  18 

Hypermetropic  or  long-sighted  eye.    Rays  of  light    away  the  ODJCCt  IS, 
focused  behind  the  retina  .  . 

the  less  its  image 

is  blurred.  Clear  vision  is  possible  for  the  hyperopic 
eye  in  one  way  only;  namely,  by  an  increase  in  the  con- 
vexity of  the  lens  sufficiently  great  to  bring  the  parallel 
rays  to  a  focus  exactly  on  the  retina.  Fortunately,  the 
crystalline  lens  is  provided  with  a  means  for  regulating 
its  convexity.  The  action  of  this  mechanism  is  known 
as  "accommodation."  Accommodation  consists  essen- 
tially in  releasing  the  tension  of  the  suspensory  liga- 
ment of  the  lens  through  the  action  of  the  ciliary 
muscle.  This  enables  the  lens  to  increase  its  convexity 

by  virtue  of  its 
inherent  elastic- 
ity. When  the 
ciliary  muscle 
contracts,  the 
pressure  on  the 

IS     in     Dart 

r»f»rrnit- 
PCJ 

•  .       U  „,„„„,„ 
1U,    uecduac 

,    ..          ,       ..    ., 

of  its  elasticity, 
to  assume  a  more  nearly  globular  shape.  (Fig.  19.)  The 
nearer  the  object  is  to  the  eye,  the  more  the  ciliary 


FIO  19 

Diagram  to  illustrate  accommodation.  On  the  left, 
the  form  taken  by  the  lens  at  rest  and  viewing  dis- 
tant objects  is  shown  ;  on  the  right,  that  when  ac- 
commodated  for  near  objects.  Sc,  sclerotic  ;  C.  P., 
ciliary  processes  ;  Sp.L.,  suspensory  ligament  ;  C.L., 
crystalline  lens.  (From  Thornton's  "Advanced 
Physiology.") 


THE  HYGIENE  OF  VISION  249 

muscle  must  exert  itself.  It  will  be  observed  also  that 
the  emmetropic  eye,  the  eye  which  focuses  the  rays 
from  distant  objects  upon  the  retina  without  effort, 
must  resort  to  accommodation  when  near  objects  are 
fixated.  The  normal  eye  can  secure  rest  from  the  strain 
of  accommodation  simply  by  looking  away  from  the 
book  or  other  near  object  to  something  in  the  distance, 
but  the  ciliary  muscle  of  the  badly  hyperopic  eye  ordi- 
narily receives  no  rest.  It  can  be  relieved  only  by  an 
artificial  convex  lens  which,  placed  in  front  of  the  eye, 
takes  the  strain  off  the  crystalline  lens,  so  to  speak,  and 
places  it  upon  the  glasses. 

(3)  Sometimes  the  eye  is  too  long  from  front  to 
back,  so  that  parallel  rays  are  brought  to  focus  before 
they  strike  the  re- 
tina. (Fig.  20.) 
This  condition  is 

known  as  "myo- 
.    ,,  «  FIG.  20 

pia,          Or          near-      Myopic  or  short-sighted  eye.   Bays  of  light  focused 
•     i   ...     i  •  in  front  of  the  retina 

sight.     In  myopia 

there  is  no  possibility  of  clear  vision  for  distant  ob- 
jects, since  contraction  of  the  ciliary  muscle  would 
increase  the  convexity  of  the  lens  and  so  make  mat- 
ters worse.  Objects  close  enough  are  distinctly  imaged 
in  myopia.  But  however  great  the  myopia  and  how- 
ever badly  it  interferes  with  ordinary  vision,  no  strain 
of  accommodation  results.  The  only  eye-strain  pro- 
duced by  myopia  is  the  strain  upon  the  oculo-motor 
muscles  which  are  attached  at  the  rear  of  the  eyeball. 
These,  in  looking  at  very  near  objects,  must  exert  a 


250    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

constant  pull  to  converge  the  two  eyes  upon  the  ob- 
ject, held,  as  is  often  the  case,  but  a  few  inches  dis- 
tant. 

(4)  In  the  simple  myopia  and  simple  hyperopia  just 
described  the  source  of  imperfection  lies  solely  hi  the 
length  of  the  anterior-posterior  diameter  of  the  eyeball. 
If  this  diameter  is  too  short,  we  have  hyperopia;  if  too 
long,  myopia.  But  there  is  another  source  of  defect; 
namely,  uneven  curvature  of  the  cornea  or  lens  (usu- 
ally the  cornea).  This  is  known  as  "astigmatism."  In 
astigmatism  the  cornea  (or  else  the  lens)  has  "different 
curvatures  in  different  meridians"  (diameters),  so  that 
only  blurred,  or  partly  blurred,  images  are  formed.  The 
rays  of  light  from  an  object  may  focus  partly  in  front, 
partly  behind,  and  partly  on  the  retina.  Five  varieties 
of  astigmatism  are  possible,  as  follows:  — 

TABLE  26 

Varieties  Focus  from  one  Focus  from  other 

extreme  diameter  extreme  diameter 

Simple  hyperopic  On  retina  and  Behind  retina 

Compound  hyperopic  Behind  retina  and  Behind  retina 

Simple  myopic  On  retina  and  In  front  of  retina 

Compound  myopic  In  front  of  retina  and  In  front  of  retina 

Mixed  In  front  of  retina  and  Behind  retina 

If  not  too  severe,  most  of  the  forms  of  astigmatism 
can  be  corrected,  or  partly  corrected,  by  the  action  of 
the  ciliary  muscle.  The  same  is  true  of  hyperopia.  If,  in 
spite  of  the  astigmatic  or  hyperopic  shape  of  the  eye, 
clear  vision  results  by  virtue  of  accommodation,  we 
have  the  condition  described  as  "latent  astigmatism" 
or  "latent  hyperopia."  Correction  is  made,  but  at  the 


THE  HYGIENE  OF  VISION  251 

cost  of  eye-strain.  When  the  strain  becomes  too  great 
and  correction  is  no  longer  possible,  the  defect  is 
described  as  "manifest."  Hence  astigmatism  and  hy- 
peropia  are  the  two  causes  of  overstrain  of  the  ciliary 
muscle.  Relief  from  astigmatism  is  secured  by  glasses 
ground  in  such  a  way  as  to  have  also  "different  curva- 
tures in  different  meridians,"  but  the  reverse  of  the 
difference  between  the  two  meridians  of  the  eye  and  so 
correcting  it. 

Let  us  now  consider  each  of  the  above  conditions  in 
greater  detail. 

Emmetropia  (correct  vision) 

No  human  eye  is  absolutely  perfect,  and  few  even 
approximately  so.  The  great  Helmholz  l  is  said  to 
have  remarked  that  he  would  instantly  discharge  any 
laboratory  assistant  who  had  prepared  for  his  use  an 
optical  instrument  as  imperfect  as  the  most  perfect 
human  eye.  George  M.  Gould  claims  to  have  found 
no  perfect  eye  out  of  10,000  pairs  examined  (8).  Jack- 
son (13)  reports  51  eyes  out  of  4000  as  emmetropic,  or 
1.3  per  cent. 

But  nature's  adaptations  are  seldom  perfect,  and 
faults  of  structure  or  functioning  could  probably  be 
made  out  for  almost  any  organ  of  the  body.  Slight 
imperfections  of  the  eye  do  not  greatly  hinder  vision, 
and  from  hah*  to  two  thirds  of  the  people  get  along 
fairly  comfortably  with  the  optical  apparatus  nature 
has  given  them. 

1  Physicist,  physiological-psychologist,  and  inventor  of  the  oph- 
thalmoscope. 


252    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

Not  so,  however,  with  a  large  minority.  Of  about 
500,000  children  examined  in  the  elementary  schools  of 
London,  10  per  cent  had  not  more  than  one  third  nor- 
mal vision.  Examinations  of  87,000  pupils  in  the  Rus- 
sian secondary  schools  showed  that  the  incidence  of 
myopia  alone  ranged  from  8.8  per  cent  in  the  lower 
grades  to  22.6  per  cent  in  the  highest. 

Out  of  79,065  children  examined  in  the  public  schools 
of  New  York  City  (1906),  31  per  cent  are  reported  as 
having  defective  vision.  For  the  entire  State  of  Massa- 
chusetts (402,937  children)  the  proportion  of  children 
with  defective  vision  was  returned  in  1907  as  22.3  per 
cent.  In  Cleveland  (30,045  children)  the  proportion 
was  20.7  per  cent;  in  Minneapolis  (25,696  children), 
30  per  cent;  in  Worcester  (11,953  children),  19.1  per 
cent;  suburban  schools  near  St.  Louis  (2000  children), 
30.6  per  cent.  Dr.  E.  B.  Hoag  finds  30  per  cent  for 
15,000  children  in  the  towns  and  cities  of  Minnesota. 

Statistics  from  about  165,000  school  children  in 
Japan  gave  the  following  results  (18) :  — 


TABLE  27 

Kind  of  school                   Number  examined 

Defective  vision 

'Middle  schools                      92,290 

12.4  per  cent 

Boys 

Normal  schools                      11,963 

16.6 

Technical  schools                  28,115 

12.8 

Professional  schools                 1,631 

28.8 

Girls  f  High  schools                         27,191 

9.4 

\  Normal  schools                       4,018 

7.6 

The  above  statistics,  chosen  from  innumerable  in- 
vestigations in  diverse  parts  of  the  world,  amply  demon- 
strate that  from  10  to  30  per  cent  of  the  school  pop- 
ulation have  vision  sufficiently  imperfect  to  demand 


THE  HYGIENE  OF  VISION  253 

correction  by  glasses.  The  conditions  in  different  cit- 
ies and  countries  are  probably  more  uniform  than 
the  figures  presented  would  indicate,  the  statistics 
depending  in  part  upon  the  methods  of  testing  and  in 
part  upon  the  varying  standard  as  to  the  degree  of 
defectiveness  which  may  be  safely  disregarded. 

Hyperopia  ("far-sight") 

As  already  explained,  hyperopia  is  due  to  a  too  short 
diameter  of  the  eye  from  front  to  back.  Examinations 
made  by  various  investigators  of  more  than  2000  day- 
old  babies  prove  conclusively  that  hyperopia  is  the 
normal  condition  at  birth  (29).  As  age  increases,  the 
eye  changes  gradually  from  the  condition  of  hyper- 
opia to  that  of  emmetropia  (normal  vision),  and  later, 
in  many  cases,  to  myopia.  In  London  school  children 
the  proportion  of  hyperopia  decreases  rather  regu- 
larly from  45  per  cent  at  6  years  to  18  per  cent  at  13 
years.1 

Similar  figures  could  be  quoted  in  great  number,  but 
the  following  table  of  results  from  the  Gymnasium  at 
Altona,  Germany,  will  sufficiently  illustrate  the  law 
of  decreasing  hyperopia  as  the  eye  evolves. 

1  It  is  important  to  distinguish  the  hyperopia  of  childhood  from 
the  condition  of  far-sight  commonly  found  in  persons  somewhat  past 
middle  age.  The  former  condition  is  ordinarily  due  to  the  fact  that 
the  eye  is  undeveloped.  The  latter  condition,  known  as  "presby- 
opia," is  due  to  the  decrease  in  the  power  of  accommodation  which 
usually  takes  place  after  the  age  of  thirty-five  or  forty  years.  Most 
persons  at  this  age  would  do  well  to  have  the  eyes  tested  for  pres- 
byopia. 


254    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

TABLE  28 

Age  Number  hypermetropic 

9-11  18.93  per  cent 

12-14  7.14 

15-17  6.88 

18-20  4.05 

21-22  0.00 

The  significance  of  hyperopia  lies  chiefly  in  the 
strain  it  throws  upon  the  ciliary  muscle  in  the  effort 
to  produce  accommodation.  Another  serious  result 
frequently  produced  by  hyperopia  is  "squint,"  or 
"cross-eye."  l  The  emmetropic  (normal)  eye  demands 
effort  on  the  part  of  the  ciliary  muscle  during  "near 
work";  the  hyperopic  eye  always.  Any  considerable 
degree  of  hyperopia,  uncorrected  by  glasses,  is  there- 
fore a  constant  source  of  eye-strain.  It  is  much  the 
same  as  if  any  other  muscles  were  compelled  to  work 
without  a  moment's  rest  except  during  sleep.2 

Whether  hyperopia  should  be  corrected  by  glasses 
depends  upon  the  degree  of  the  defect,  the  age  of  the 
child,  and  the  general  condition  of  health.  Mild  hyper- 
opia in  the  early  years  is  perfectly  normal,  and  the  only 
caution  necessary  in  such  cases  is  the  avoidance  of  an 
excessive  amount  of  near  work.  If  the  health  is  good, 
a  fairly  high  degree  of  the  defect  may  be  corrected  by 
accommodation  without  symptoms  of  eye-strain.  On 

1  See  p.  263. 

*  It  should  be  stated,  however,  that  if  the  degree  of  hyperopia  is 
so  great  that  the  ciliary  muscle  cannot  make  even  approximate  cor- 
rection, the  effort  of  accommodation  is  relaxed  and  the  eye  accepts 
the  blurred  vision  as  inevitable.  In  this  event  there  is  poor  vision 
without  eye-strain. 


THE  HYGIENE  OF  VISION  *55 

the  other  hand,  if  the  health  is  poor  and  the  "tone" 
of  the  muscles  reduced,  a  relatively  slight  hyperopia 
may  give  rise  to  marked  symptoms.  The  oculist  alone 
is  competent  to  judge  whether  glasses  are  needed. 

When  the  hyperopia  is  very  great,  correction  by 
glasses  is  always  necessary.  Neglect  of  such  children 
is  nothing  less  than  cruelty.  The  extremely  hyperopic 
eye  works  as  hard  at  distant  vision  as  the  normal  eye 
at  near  work.  Let  the  person  with  normal  eyes  focus 
them  upon  an  object  distant  twelve  inches  and  attempt 
to  retain  this  focus  for  fifteen  consecutive  hours  and  he 
will  gain  an  idea  of  the  strain  to  which  the  extremely 
hyperopic  person  is  all  the  time  subjected.  Little  won- 
der that  the  nerves  should  be  shattered  and  the  general 
health  disturbed  by  a  strain  so  far  beyond  the  power  of 
any  muscle  to  endure! 

Myopia 

No  question  in  school  hygiene  has  given  rise  to  more 
controversy,  or  to  more  error,  than  myopia.  Certain 
aspects  of  the  problem  which  had  been  in  dispute  for 
over  a  hundred  years  are  only  now  being  cleared  up, 
and  the  most  erroneous  statements  are  still  common  \  *f 
both  in  the  literature  of  school  hygiene  and  in  medical 
treatises. 

Over  half  a  century  ago  it  was  clearly  shown  by 
Cohn  that  myopia  increases  rapidly  in  the  upper 
grades,  reaching  often  as  high  as  40  or  50  per  cent  by 
the  age  of  20  years.  This,  it  was  assumed,  was  due  en- 
tirely to  the  near  work  of  the  school. 


It  was  assumed  further  that  myopia  of  any  degree 
is  pathological  and  tends  to  run  a  progressive  course. 
"The  myopic  eye  is  a  diseased  eye,  and  the  school  is  its 
cause,"  was  the  slogan  of  reform.  It  was  believed  that 
the  defect  was  produced  solely  by  the  excessive  con- 
vergence required  of  the  eyes  when  a  near  object  is 
fixated,  the  pull  of  the  oculo-motor  muscles  on  the 
coats  of  the  eye  at  the  rear  gradually  lengthening  the 
eye-ball.  The  myopia  thus  induced  would,  of  course, 
require  objects  to  be  brought  still  nearer  the  eye  for 
clear  vision,  which,  hi  turn,  would  require  still  greater 
convergence,  resulting  in  increased  myopia,  and  so  on. 
This  is  what  is  meant  by  the  statement  that  myopia 
tends  to  be  "progressive,"  or  to  run  in  a  "vicious 
circle."  It  was  also  emphasized  that  finally  the  exces- 
sive pull  required  for  convergence  would  inevitably 
result  in  other  pathological  conditions  of  the  coats 
of  the  eye. 

Further  proof  of  the  contention  that  myopia  is 
always  pathological  and  that  it  is  chiefly  induced  by 
the  abuse  of  near  vision  was  sought  in  statistics  which 
purported  to  show  that  it  is  not  present  in  primitive 
races,  and  that  its  frequency  is  always  in  proportion 
to  the  amount  of  near  work  required.  Myopia  came  tc 
be  known  as  "school  myopia." 

The  defect  was  even  considered  by  some  writers  an 
important  factor  in  character  formation,  causing,  it  was 
believed,  stubbornness,  melancholia,  timidity,  abou- 
lia,1  phobias  of  people  or  ghosts,  superstition,  etc. 

1  Weakness  of  the  will  resulting  in  inability  to  make  decisions. 


THE  HYGIENE  OF  VISION  «57 

On  the  other  hand,  opponents  of  this  view  have  con- 
tended that  school  statistics  always  exaggerate  the 
amount  of  myopia  through  frequent  failure  to  distin- 
guish it  from  other  forms  of  defective  vision;  that  the 
much-talked-about  pathological  effects  of  myopia  are 
discoverable  only  in  rare  cases;  that  severe  myopia  is 
not  uncommon  in  children  below  school  age  and  hi 
uneducated  peasants  who  have  never  gone  to  school 
or  used  their  eyes  for  other  forms  of  near  work;  and 
that  whatever  increase  takes  place  during  school  life 
is  in  part  the  result  of  the  natural  evolution  of  the  eye 
and  in  part  represents  a  favorable  adaptation  of  the 
eye  to  the  demands  made  upon  it.  Some  have  gone  so 
far  as  to  assert  that  a  moderate  degree  of  myopia  is  the 
ideal  condition,  and  that  if  it  were  possible  to  prevent 
myopia  it  would  be  a  grave  mistake  to  do  so. 

Space  does  not  permit  us  to  enter  into  the  details 
of  this  interesting  Hundred  Years'  War,  the  wavering 
fortunes  of  which,  as  recorded  in  the  narrative  of 
Wingerath  (29),  read  like  a  modern  Iliad. 

Let  us,  if  possible,  escape  the  bias  of  the  violent  par- 
tisan and  base  our  conclusions  upon  reliably  established 
facts,  remembering  that  the  cause  of  school  hygiene 
cannot  be  permanently  served  by  an  exaggeration  of 
its  claims. 

Among  the  essential  facts  are  the  following:  — 

(1)  Myopia  is  by  no  means  unknown  among  primi- 
tive races,  though  its  exact  frequency  has  not  been 
sufficiently  established  for  many  tribes. 

(2)  Investigations  of  eye  conditions  among  army 


<r  <r 

258    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

recruits  in  Germany  and  Denmark  have  revealed  the 
presence  of  all  degrees  of  myopia  in  recruits  who  had 
never  attended  school  or  engaged  in  near  work  of  any 
kind.  Although  most  of  these  studies  agree  in  finding 
a  larger  proportion  of  myopia  among  recruits  who  had 
attended  school  longest,  one  investigation,  at  least, 
finds  exactly  the  reverse. 

(3)  The  fact  that  myopia  becomes  much  more  fre- 
quent in  the  upper  grades  is  admitted  by  all,  but  that 
the  school  is  the  chief  culprit  remains  to  be  proved.  The 
evolution  of  the  eye  from  a  condition  of  hyperopia  to 
one  of  myopia  has  been  frequently  observed  among 
those  who  have  attended  school  little  or  none  at  all. 
The  presence  of  more  myopes  in  the  upper  classes  is 
also  partly  accounted  for  on  the  theory  that  inasmuch 
as  extreme  near-sight  unfits  the  child  for  ordinary  dis- 
tant seeing  but  leaves  the  ability  to  read  little  impaired, 
children  with  myopia  are  for  this  reason  more  likely  to 
be  retained  in  school  and  to  crowd  the  upper  grades. 

The  most  reliable  statistics,  such  as  those  of  Red- 
slob  (21),  Krusius  (15),  and  Khlopine  indicate  that 
myopia  is  about  as  common  in  those  types  of  schools 
demanding  the  least  amount  of  near  work  as  in  those 
demanding  most.  Moreover,  no  very  appreciable  de- 
crease in  the  proportion  of  myopes  among  school 
children  seems  to  have  taken  place  as  the  result  of  the 
modern  crusade  for  school-hygiene  reform,  although  re- 
markable advances  have  been  made  in  school-lighting, 
bookmaking,  etc.  While  it  cannot  be  denied  that  the 
school  may  be  one  factor  in  the  production  of  myopia, 


THE  HYGIENE  OF  VISION  259 

that  it  is  the-  sole,  or  even  the  chief,  factor  can  no 
longer  be  maintained. 

(4)  The  investigations  of   Stilling,   Steiger,   Miss 
Barrington,  and    Karl    Pearson  amply  demonstrate 
the  hereditary  character  of  myopia.    On  the  basis  of 
more  than  5000  measurements  made  on  cadavers, 
Stilling  claims  that   the  development  of  myopia  is 
mainly  dependent  on  the  conformation  of  the  bony 
socket  of  the  eye,  a  low  orbit  predisposing  to  the  defect. 
This,  of  course,  is  hereditary  in  the  same  degree  as  any 
other  skeletal  peculiarity. 

(5)  It  will  be  impossible  to  clear  up  the  mysteries  of 
myopia  as  long  as  all  kinds  and  degrees  of  the  defect 
are  thrown  together  for  wholesale  consideration.    As 
regards  both  the  cause  and  the  results  of  myopia,  it  is 
necessary  to  distinguish  two  types:  (a)  pathological 
myopia,  and  (6)  functional  myopia. 

Pathological  myopia  is  usually  of  high  degree  and 
represents  a  definitely  diseased  condition  of  great  seri- 
ousness. Of  this  type,  it  is  correct  to  say  that  "the 
myopic  eye  is  a  sick  eye";  and  we  may  add  that  it  is 
myopic  largely  because  it  is  sick,  not  sick  simply  be- 
cause it  is  myopic.  This  form  of  myopia  runs  a  pro- 
gressive course. 

Functional  myopia,  on  the  contrary,  is  usually  of 
low  degree,  appears  ordinarily  in  late  childhood  or 
early  adolescence,  and  becomes  fully  arrested  before 
the  age  of  twenty-five.  The  best  authorities  at  present 
believe  that  this  type  of  myopia  rarely,  if  ever,  passes 
over  into  the  pathological  type.  It  is  a  defect  which, 


260    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

although  it  may  handicap  its  possessor  for  certain 
kinds  of  work,  is  unlikely  to  have  serious  consequences. 
In  all  probability  it  is  the  joint  product  of  two  factors  : 
(a)  a  low  orbit  (which  is  hereditary),  and  (6)  an  exces- 
sive amount  of  near  work,  such  as  reading,  writing, 
sewing,  etc.  It  has  not  been  demonstrated  that  factor 
(6)  operating  alone  is  responsible  for  any  large  pro- 
portion of  the  cases. 

(6)  The  functions  of  school  hygiene  with  respect  to 
myopia  are  fairly  definite.  In  the  first  place,  it  is  ex- 
tremely important  to  identify  those  children  who  have 
a  tendency  to  "pathological  myopia."  These  should 
remain  under  the  constant  supervision  of  the  oculist. 
In  the  second  place,  the  school  should  do  everything 
possible  to  clear  itself  from  the  suspicion  of  causing 
"functional  myopia."  Lighting,  seating,  textbooks, 
and  the  hygienic  arrangement  of  the  daily  program, 
including  rest  periods,  are  the  cardinal  points  here.  If 
it  is  correct,  as  seems  probable,  that  the  chief  cause  of 
myopia  lies  in  the  shape  of  the  eye's  orbit,  then  it 
would  be  possible  to  identify  in  the  first  grade  those 
who  are  likely  to  develop  the  defect  later.  Appropriate 
means  could  then  be  employed  to  safeguard  such  chil- 
dren from  needless  injury  to  their  sight.1 

AstigmatisnKL 

The  discovery  of  astigmatism  by  Thomas  Young 
over  a  hundred  years  ago,  and  the  later  demonstration 

1  See  the  admirable  discussion  of  myopia  by  Professor  W.  H. 
Burnham,  in  Monroe's  Encyclopedia  of  Education. 
*  For  definition  see  D.  250. 


THE  HYGIENE  OF  VISION  261 

by  Bonders  that  it  is  due  to  an  error  of  refraction, 
constitute,  together,  one  of  the  most  important  medi- 
cal advances  of  the  last  century.  Astigmatism  is  re- 
sponsible for  more  than  hah*  the  cases  of  seriously  im- 
paired vision  and  for  the  majority  of  cases  of  eye-strain. 

In  the  period  1908-11,  the  school  physicians  of 
Strassburg  referred  2033  children  to  the  school  oculist 
for  special  examinations.  Among  these  there  were  679 
eyes  hyperopic,  588  myopic,  and  1496  astigmatic. 
Astigmatism  was,  therefore,  more  than  17  per  cent 
more  frequent  than  hyperopia  and  myopia  combined. 

Few  eyes  are  entirely  free  from  astigmatism.  Of 
2307  school  children  examined  by  Dr.  Stocker,  in 
Lucerne,  Switzerland,  96.7  per  cent  had  astigmatism 
of  at  least  .25  D  in  one  or  both  eyes.  Statistics  usually 
show  that  not  far  from  10  or  15  per  cent  of  the  school 
children  have  astigmatism  sufficiently  great  to  impair 
vision  seriously.  The  statistics  secured  by  Steiger 
(24)  are  typical.  In  the  cities  of  Zurich  and  Berne 
(Switzerland),  7736  children  out  of  25,995  whose  ages 
lay  between  6  and  8  years  were  referred  to  the  school 
oculist,  Dr.  Steiger,  for  examination.  Of  these,  2406, 
or  slightly  less  than  10  per  cent  of  the  25,995,  were 
found  to  be  markedly  astigmatic. 

Some  forms  of  astigmatism  impose  a  peculiarly  diffi- 
cult task  upon  the  ciliary  muscle  in  the  effort  of  correc- 
tion. Sometimes  it  causes  faulty  posture,  since  the 
child  sees  more  clearly  in  one  meridian  than  in  the  other 
and  so  turns  the  head  to  one  side  in  order  to  take  ad- 
vantage of  the  meridian  of  clear  vision.  It  is  possibto 


262    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

that  preferences  as  regards  handwriting  slant  are 
sometimes  caused  by  the  astigmatic  eye  choosing  that 
slant  which  makes  the  individual  lines  stand  out  most 
clearly. 

Whether  the  child  with  a  moderate  degree  of  astig- 
matism should  be  advised  to  secure  glasses  depends  in 
large  measure  upon  the  state  of  health.  In  some  chil- 
dren, rather  severe  errors  of  refraction  cause  no  dis- 
coverable symptoms;  in  others,  marked  symptoms 
accompany  slight  errors.  Some  eyes  have  little  power 
of  correction,  and  some  nervous  systems  are  more 
subject  to  reflej^disturbances  than  others. 

There  is  no  evidence  that  astigmatism  is  caused  by 
the  school,  though  of  course  near  work  adds  very 
greatly  to  the  burden  of  the  astigmatic  eye  and  aggra- 
vates the  symptoms  of  strain.  The  cause,  in  most 
cases,  is  the  pressure  exerted  by  the  eyelids  upon  the 
ball.  Astigmatism  in  the  opposite  direction,  "con- 
trary to  the  rule,"  is  much  more  rare  in  children  than 
in  adults,  making  up  only  2.9  per  cent  of  all  the  cases 
of  astigmatism  found  by  Redslob  (21). 

Muscular  deviations 

The  muscles  which  move  the  eyeball  are  subject  to 
three  common  varieties  of  disturbance,  resulting  re- 
spectively in  squint,  unbalance,  and  muscular  insuf- 
ficiency. The  cause  of  squint  and  unbalance  is  usually 
some  form  of  ametropia  (i.e.,  far-sight,  near-sight,  or 
astigmatism),  and  not  chiefly  an  anatomic  defect  in 
the  muscles  or  their  attachment,  as  was  formerly 


THE  HYGIENE  OF  VISION  2d3 

believed.  Paralysis  will,  of  course,  produce  muscular 
deviations,  but  aside  from  this  the  cause  is  usually 
some  refractive  error. 

Squint,  or  "cross-eye,"  is  a  particularly  serious  con- 
dition of  muscular  disturbance  often  observed  in  school 
children.  The  experience  of  Dr.  E.  B.  Hoag  indicates 
that  it  can  be  detected  in  about  2  per  cent  of  the  school 
enrollment  by  means  of  ordinary  observation,  with- 
out the  use  of  any  optical  instruments.  Cornell  esti' 
mates  that  it  is  present  in  from  3  to  6  per  cent  (5), 
while  Butterworth  finds  that  it  ranges  around  2  per 
cent. 

In  the  majority  of  instances,  squint  is  caused  by 
congenital  and  excessive  hyperopia  in  one  of  the  eyes. 
The  child  early  learns  instinctively  to  disregard  the 
"bad  eye,"  which  is  soon  turned  up,  down,  in,  or  out. 
As  a  result,  the  power  to  focus  is  soon  lost  in  this  eye, 
and  if  proper  glasses  are  not  obtained  before  the  child 
is  6  or  7  years  old  (or  even  earlier),  the  sight  of  the 
crossed  eye  is  usually  greatly  reduced  or  even  lost  alto- 
gether. Some  believe  that  the  reduced  vision  comes 
solely  from  disuse;  others  that  it  is  occasioned  by  a 
lack  of  development  in  that  portion  of  the  brain  which 
is  concerned  with  the  vision  of  the  eye. 

If  the  eyes  are  to  be  straightened  without  operation 
and  the  sight  saved,  glasses  and  treatment  must  be 
provided  at  the  earliest  possible  moment,  even  if  the 
child  is  still  an  infant  in  arms.  Every  medical  examiner 
sees  many  cases  of  squint  in  which  the  vision  is  almost 
or  quite  destroyed  in  the  eye  affected.  Parents  and 


264    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

teachers  rarely  understand  the  situation,  and  are  as- 
tonished to  learn  that  the  child's  vision  is  already  seri- 
ously affected  or  past  repair. 

The  study  of  Butterworth,  already  mentioned,  is 
perhaps  the  most  valuable  in  this  field.  Of  14,739 
children  whom  he  examined,  3  to  13  years  of  age,  2.2 
per  cent  had  the  defect.  The  number  increased  from 
8  to  6  years,  after  which  it  remained  practically  sta- 
tionary. We  may  say,  therefore,  that  if  the  child  has 
binocular  vision  when  he  enters  school,  he  is  not  likely 
to  lose  it  later.  The  left  eye,  for  reasons  unknown,  was 
affected  nearly  twice  as  often  as  the  right  eye.  Only 
one  fifth  of  Butterworth's  cases  had  ever  used  glasses, 
and  only  the  insignificant  number  of  one  twenty-fifth 
of  these  had  completely  regained  binocular  vision,  the 
treatment  in  most  cases  having  come  too  late. 

Many  individuals  suffer  from  slight  unbalance  of 
the  oculo-motor  muscles  without  noticeable  squint. 
In  such  cases  there  is  either  constant  or  occasional 
impairment  of  binocular  vision,  and  always  a  nervous 
strain  from  the  effort  to  balance  the  eyes  in  maintain- 
ing steady  focus.  The  strain  may  be  unnoticed  and 
binocular  vision  retained  as  long  as  health  is  good, 
while  after  an  illness  or  during  extreme  fatigue  the 
nervous  symptoms  of  strain  may  appear  and  binocu- 
lar vision  become  intermittent  or  altogether  impossible. 

Eye-strain  in  relation  to  visual  defects 

As  already  explained,  eye-strain  may  result  either 
from  (a)  overuse  of  the  ciliary  muscle  in  producing 


THE  HYGIENE  OF  VISION  265 

accommodation,  or  (6)  excessive  effort  on  the  part  of 
the  oculo-motor  muscles  in  maintaining  eye-balance 
and  producing  convergence.  The  former  is  the  more 
common  cause. 

The  strain  of  accommodation  is  constant  in  the  hy- 
peropic  eye,  and  is  more  severe  the  nearer  the  object 
is  which  is  fixated.  Astigmatism  nearly  always  results 
in  greater  or  less  strain.  In  the  normal  eye,  also,  there 
is  strain  of  accommodation  as  long  as  near  work  is 
being  performed. 

Due  to  the  power  of  accommodation,  not  all  people 
who  have  imperfect  eyes  suffer  radical  impairment  of 
vision.  Excessive  use  of  accommodation  in  far-sighted 
and  astigmatic  persons,  however,  always  finally  results 
in  eye-strain.  This  is  particularly  likely  to  occur  in 
those  individuals  whose  work  requires  considerable 
near  vision.  In  outdoor  work  requiring  only  little  use 
of  the  eyes  for  near  vision,  no  symptoms  may  appear 
even  in  the  case  of  serious  defectiveness,  provided  the 
general  health  is  good. 

The  close  relation  existing  between  general  physical 
condition  and  the  power  of  accommodation  is  well 
demonstrated  by  the  experiments  of  Bauer.1  Testing 
the  range  of  accommodation  at  different  times  in  the 
day,  before  and  after  various  kinds  of  work,  Bauer  finds 
that  it  closely  parallels  the  daily  course  of  physical 
and  mental  efficiency  and  serves  as  an  excellent  meas- 
ure of  fatigue.  The  accompanying  figure  from  Bauer, 
in  which  vertical  distance  represents  the  range  of  ac- 
1  Die  Ermiidung  in  Spiegel  des  Auges.  1910. 


266    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

commodative  power  and  horizontal  distance  refers  to 
the  time  of  day,  shows  the  intimate  connection  be- 
tween fatigue  and  the  functional  capacity  of  the  ciliary 
muscle. 

There  are  few  things  more  important  for  the  teacher 
to  understand  than  the  in  juries  produced  by  eye-strain, 


Hour 


PIG.  21 

Showing  the  daily  curve  of  fatigue  for  eye  accommodation  during  an  entire  week 
for  one  subject.  Vertical  distance,  represented  in  centimeters,  shows  the  dis- 
tance for  which  accommodation  was  possible  at  different  times  in  the  day. 
Greater  vertical  distance  corresponds  to  a  higher  degree  of  fatigue.  Note  that 
accommodation  is  best  at  8  A.M.  and  worst  at  noon.  Note  absence  of  fatigue 
on  Saturday  and  Sunday. 

since  it  not  only  produces  local  symptoms  and  im- 
perfect vision,  but  through  its  reflex  effects  may  also 
undermine  health  altogether.  It  would  almost  seem 
as  if  the  whole  reservoir  of  nervous  energy  could  be 
exhausted  through  this  one  small  leak. 

The  signs  and  symptoms  of  eye-strain  may  be  clas- 


THE  HYGIENE  OF  VISION  267 

sified  as  local  or  general.  The  chief  local  manifestations 
are:  — 

(1)  Painful  eyes; 

(2)  Spasms  of  the  eyelids; 

(3)  Itching,  smarting,  or  watering  of  the  eyes; 

(4)  Congestion  of  the  eyes; 

(5)  Sensitiveness  to  light; 

(6)  Frowning; 

(7)  Blurred  vision. 

In  regard  to  blurred  vision,  some  interesting  and  very 
significant  answers  are  obtained  when  children  hi  the 
schools  are  asked  the  question,  "How  does  the  print 
look  to  you?"  The  following  are  representative  ver- 
batim answers  recorded  by  Dr.  Hoag  in  his  work  with 
thousands  of  pupils  hi  California  and  Minnesota. 
Of  one  group  of  over  5000  pupils  thus  questioned,  23 
per  cent  gave  such  answers  as  the  following:  — 

"The  letters  all  run  together." 

"I  see  two  lines  instead  of  one." 

"I  see  one  letter  on  top  of  another." 

"The  letters  look  crooked." 

"The  print  seems  all  jumbled  up." 

"The  letters  jump  up  and  down." 

"After  I  read  awhile,  I  can't  find  my  place  any  more." 

"The  print  looks  like  a  big  blot." 

"The  letters  seem  like  a  fog  was  over  them." 

"The  letters  look  half  up-side-down." 

The  reflex,  or  general,  symptoms  of  eye-strain  are 
legion.  Among  the  most  important  are:  — 

(1)  Headache  (often  with  nausea) ; 

(2)  Feelings  of  exhaustion  and  weakness; 


268    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

(3)  Indigestion  (sometimes  constipation) ; 

(4)  Dizziness; 

(5)  Sleeplessness; 

(6)  Neurasthenia  (fatigue  of  the  nervous  system); 

(7)  Motor  disturbances,  such  as  twitching,  automatisms, 
stuttering,  etc.; 

(8)  Irritability,  lack  of  emotional  control,  outbreaks  of 
temper,  etc. 

Of  the  reflex  symptoms,  headaches  are  the  most 
important.  Cornell  finds  that  31  per  cent  of  those  who 
have  eye-strain  suffer  frequent  headaches.  Conversely, 
headaches  (particularly  those  localized  in  the  frontal 
region  of  the  head)  should  always  suggest  the  possibil- 
ity of  eye-strain.1 

It  is  quite  generally  admitted  that  eye-strain  is 
sometimes  responsible  for  one  or  more  of  the  other 
general  symptoms  above  listed,  though  not  all  are 
ordinarily  present  in  any  one  case.  There  is  reason  to 
believe,  also,  that  it  may  occasionally  act  as  the  pro- 
verbial "last  straw"  in  the  production  of  chorea, 
habit-spasms,  moral  delinquency,  or  even  functional 
epilepsy. 

Teachers  should  never  forget  that  ability  to  read  the 
vision  charts  at  the  normal  distance  is  no  guaranty 
that  eye-strain  is  not  present.  In  many  cases  of  fairly 
severe  hyperopia  and  astigmatism,  the  child  is  able  to 
read  the  chart  simply  by  bringing  an  excessive  amount 
of  accommodation  into  play.  The  only  means  of  ascer- 
taining the  actual  refractive  error  of  the  eye,  and  there~ 
fore  the  amount  of  strain  to  which  it  is  subjected,  is  to 
1  See  chapter  xv. 


THE  HYGIENE  OF  VISION  269 

prevent  accommodation  during  the  test  by  paralyzing 
the  ciliary  muscle.  This  the  oculist  accomplishes  by 
dropping  into  the  eye  one  of  the  forms  of  belladonna. 

Since  this  precaution  cannot  be  taken  in  routine 
examinations  of  eyes  by  the  teachers  or  school  doctors, 
it  is  extremely  important  that  the  teacher  be  able  to 
supplement  the  tests  by  the  detection  of  the  general 
and  local  symptoms  of  eye-strain.  Because  of  her  con- 
stant presence  with  the  children  during  their  near  work, 
the  teacher  is  in  better  position  to  discover  such  symp- 
toms than  the  school  doctor  or  any  one  else.  Children 
in  whom  teachers  observe  either  general  or  local  symp- 
toms of  eye-strain  should  be  referred  to  the  oculist  for 
thorough  examination.  There  should  be  a  school  ocu- 
list for  this  purpose.  If  there  is  none,  the  parents  should 
be  urged  to  avoid  the  risky  but  common  practice  of 
consulting  an  optician.1  There  are  so  many  possible 
sources  of  error  in  prescribing  for  glasses,2  that  only 
the  expert  should  be  entrusted  with  it. 

Directions  for  testing  the  vision  of  school  children3 

In  testing  the  eyes  of  children  in  the  schools  no  elab- 
orate optical  apparatus  is  essential,  or,  indeed,  desir- 
able. The  tests  may  and  ought  to  be  made  by  every 
teacher  and  the  results  carefully  recorded  for  use.  Dr. 

1  An  oculist  is  a  physician  who  has  specialized  on  the  diseases  and 
disabilities  of  the  eye.  An  optician  is  a  person  who  makes  or  sells 
glasses. 

1  At  least  seventy-eight,  according  to  Dr.  Gould. 

*  This  section  has  been  prepared  with  the  assistance  of  Dr.  Frank 
Allport,  of  Northwestern  University,  to  whom  the  author  is  indebted 
for  many  kindnesses. 


270    THE   HYGIENE  OF  THE  SCHOOL  CHILD 

Frank  Allport,  Dr.  R.  C.  Cabot,  Dr.  Myles  Standish, 
Dr.  Clarence  Blake,  as  well  as  other  physicians  and 
oculists,  have  long  contended  that  the  ordinary  rou- 
tine examinations  of  the  eyes  should  be  undertaken  by 
teachers  and  school  nurses.  The  teacher  can  make  the 
tests  fully  as  well  as  can  the  physician  who  is  not  also 
an  oculist,  and  by  virtue  of  her  constant  opportunity 
to  observe  the  symptoms  of  eye-strain  among  her  pupils 
she  is  in  even  better  position  than  the  school  doctor 
to  single  out  the  children  who  need  to  be  referred  to  an 
oculist.  The  tests  will  reveal  the  worst  cases  of  defec- 
tive vision,  and  symptoms  of  eye-strain  will  reveal 
many  others  if  the  teacher  is  observant.  In  the  words 
of  Allport,  "Teachers  should  not  attempt  to  diagnose 
diseases,  but  by  means  of  simple  tests,  tests  which  can 
be  given  by  any  one  with  intelligence  enough  to  teach, 
they  can  detect  almost  all  serious  diseases  and  defects 
of  the  eye,  ear,  nose,  and  throat.  The  doctor  consulted 
will  do  the  rest." 

By  this  means,  all  the  pupils  of  a  school  system,  how- 
ever large,  can  be  tested  for  vision  in  one  day;  or,  if 
preferred,  a  few  pupils  can  be  examined  each  day  until 
the  work  is  completed.  "The  teacher  should  by  no 
means  regard  such  tests  as  a  hardship.  By  giving  only 
a  little  time  to  them  she  will  lighten  her  labors  by 
sometimes  transforming  the  nerve-exhausting,  bother- 
some, and  retarded  pupil  into  one  who  is  easily  taught 
and  ordinarily  tractable." 

For  carrying  out  these  tests  each  school  should  be 
•mpplied  with  one  of  the  standard  eye-charts  made  for 


THE  HYGIENE  OF  VISION  271 

this  purpose.  The  Allport  charts  are  to  be  recom- 
mended for  the  reason  that  they  are  designed  for  the 
special  use  of  teachers  and  nurses.  Full  instructions 
are  printed  at  the  bottom  of  the  chart.  This  part  may 
readily  be  detached  and  kept  before  the  examiner  for 
convenient  reference  while  the  test  is  being  given.  The 
Allport  charts  have  also  the  advantage  of  cheapness, 
the  price  quoted  being  but  seven  cents  each  in  quanti- 
ties of  ten  or  more.  Single  charts  may  be  had  for 
twenty-five  cents.  At  the  price  of  seven  cents  there  is 
no  school  system  which  cannot  afford  to  supply  a  vi- 
sion chart  for  every  classroom.1 

In  testing  the  eyes  of  young  children  the  cards  de- 
vised by  McCallie  are  very  desirable.2  These  consist 
of  a  series  of  small  cards  on  each  of  which  is  a  boy, 
a  girl,  and  a  bear.  The  test  requires  the  child  to  tell 
who  has  the  ball  (a  black  dot  visible  at  twenty  feet). 

In  no  case  should  the  vision  test  be  made  when 
the  child  has  a  cold  in  the  eyes,  or  when  they  are  in- 
flamed from  other  causes. 

Teachers  and  nurses  will  do  well  to  be  cautious  in 
recording  the  results  of  vision  tests,  as  there  is  a  con- 
stant tendency  to  overestimate  the  number  of  defects. 
All  children  are  likely  to  miscall  and  transpose  certain 
letters,  and  this  must  be  taken  into  account.  It  is  only 
required  that  the  child  read  the  majority  of  the  letters 
at  the  required  distance  without  undue  hesitation.  In 

1  The  charts  may  be  purchased  of  F.  A.  Hardy  &  Co.,  Wabash 
Avenue,  Chicago,  Illinois. 
1  Edwin  Fitageorge,  agent,  Trenton,  New  Jersey. 


272    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

general  it  will  be  discovered  that,  when  tested  by  the 
rough  methods  here  indicated,  from  15  to  30  per  cent 
of  school  children  have  defective  vision.  Results  which 
run  much  above  or  below  these  figures  must  ordinarily 
be  suspected  of  containing  error. 

For  practical  purposes  the  chart  for  testing  astig- 
matism is  of  little  value  in  routine  school  work.  The 
absolute  necessity  of  observing  and  recording  every 
case  of  crossed-eye  should  not  be  forgotten. 

Sometime  before  the  child  leaves  school  he  should 
also  be  given  the  test  for  color-blindness.  This  is  best 
done  by  means  of  the  Holmgren  wool  test.  To  make 
the  test  quickly,  place  before  the  child  a  green  skein 
of  Holmgren  worsted  and  have  him  match  it  from  a 
bunch  of  "confusion  skeins"  of  different  colors.  If  this 
is  done  quickly  and  without  hesitation  the  child  is 
passed.1 

About  4  per  cent  of  the  boys  and  one  hah*  of  1  per 
cent  of  the  girls  are  more  or  less  color-blind,  inability 
to  distinguish  red  and  green  being  the  most  common 
form  of  the  defect.  Tests  for  color-blindness  are  quite 
necessary  in  the  case  of  those  who  expect  to  take  up 
such  work  as  railroading,  marine  service,  medicine, 
painting,  chemistry,  mineralogy,  certain  mercantile 
businesses,  etc.  Simply  to  let  the  child  name  the  colors 
of  things  shown  him  is  not  sufficient.  Color-blind 
persons  often  learn  the  right  names  for  colors  merely 
by  their  differences  in  brightness,  while,  on  the  otheJ 

1  More  accurate  testa  for  color-blindness  and  color-weakness  may 
be  found  in  Whipple's  Manual  of  Mental  and  Physical  Tests. 


THE  HYGIENE  OF  VISION  275 

hand,  some  children  who  are  not  color-blind  do  not 
know  the  names  for  the  different  colors.  Hence  the 
necessity  of  the  Holmgren  test. 

Summary  and  conclusions 

(1)  From  15  to  30  per  cent  of  school  children  have 
seriously  defective  vision.    This  would  mean  that  in 
the  public  schools  of  the  United  States  there  are  from 
3,000,000  to  6,000,000  such  children. 

(2)  It  is  now  known  that  the  part  played  by  the 
school  in  causing  eye  defects  is  not  as  serious  as  it  was 
formerly  believed  to  be.   This  is  particularly  true  of 
myopia,  in  the  production  of  which  the  shape  of  the 
orbit  of  the  eye  (which  is  a  matter  of  heredity)  is  prob- 
ably the  leading  factor.   Near  work,  however,  favors 
the  development  of  the  defect. 

(3)  While  the  school  is  not  a  leading  cause  of  refrac- 
tive errors  of  vision,  its  responsibility  in  relation  to  the 
eye  is  very  great.  This  responsibility  lies  chiefly  in  the 
avoidance  of  eye-strain.  The  biological  development  of 
the  eye  has  not  fitted  it  for  the  kind  of  work  which  the 
school  predominantly  requires.   Eye-strain  is  usually 
present  in  astigmatism  and  hyperopia,  and  the  normal 
eye  itself  may  suffer  strain  from  the  abuse  of  near 
work. 

(4)  Eye  defects  are  intimately  related  to  faulty  pos- 
ture, both  as  cause  and  effect.   Myopia  often  leads  to 
stoop  shoulders,  and  astigmatism  is  one  factor  in  pro- 
ducing lateral  curvatures.    Conversely,  stooping  pos- 
tures and  habits  of  holding  the  book  too  near  the  eyes 


274    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

often  cause  eye-strain  and  favor  the  development  of 
functional  myopia. 

(5)  Tests  of  vision  in  the  school  should  be  made  by 
teachers  and  school  nurses.  This  not  only  results  in  a 
great  saving  of  expense,  but  is  the  only  plan  which  gives 
the  teachers  the  intimate  knowledge  which  they  need 
to  have  regarding  the  eye  conditions  of  their  pupils. 
By  Unking  this  knowledge  with  the  daily  observations 
of  eye-strain  symptoms,  teachers  will  be  better  able 
than  the  school  physician  to  single  out  those  children 
who  need  to  be  examined  by  an  oculist. 

(6)  Schools  have  not  paid  sufficient  attention  to  the 
correction  of  eye  defects.  Too  often  the  parents  neg- 
lect the  advice  of  the  school  altogether  or  else  resort 
to  the  optician  for  prescriptions.    The  experience  of 
Strassburg,  Zurich,  Berne,  and  certain  English  cities 
proves  conclusively  that  the  one  effective  way  to  secure 
results  in  this  field  is  by  the  employment  of  school  ocu- 
lists in  sufficient  numbers  to  make  a  thorough  exami- 
nation of  all  the  cases  of  defective  vision  discovered  by 
the  teacher,  nurse,  or  school  doctor.  Where  this  is  done, 
practically  all  the  children  who  are  advised  to  do  so 
present  themselves  for  such  examinations  and  nearly 
all  secure  the  glasses  needed.  By  the  plan  usually  fol- 
lowed in  America  seldom  more  than  30  to  40  per  cent  of 
the  eye  defects  are  reported  as  treated,  and  the  propor- 
tion of  adequate  treatments  must  be  very  low  indeed.1 
A  further  guaranty  of  results  is  the  plan,  quite  preva- 

1  See  Gulick  and  Ayres,  The  Medical  Inspection  of  Schools,  1913 
edition,  pp.  92  jf. 


THE  HYGIENE  OF  VISION  275 

lent  in  England,  of  supplying  the  glasses  at  wholesale 
prices,  or  even  gratuitously  in  cases  of  poverty.  A 
great  saving  is  thus  effected,  and  the  purpose  of  the 
whole  scheme  of  effort  is  attained  to  an  extent  possible 
in  no  other  way.  The  argument  that  the  private  prac- 
titioner may  suffer  from  the  adoption  of  this  plan  has 
no  weight.  Eye  defects,  like  all  others  which  afflict 
school  children,  are  to  be  conceived  as  an  evil  to  be 
corrected,  not  as  a  resource  to  be  conserved  for  the 
benefit  of  private  individuals. 

(7)  The  school  should  take  greater  precaution  than 
it  ordinarily  has  done  to  secure  the  early  diagnosis  (and 
correction)  of  refractive  errors.  It  is  foolish  to  withhold 
relief  until  eye-strain  has  aggravated  the  defect  and 
jeopardized  the  entire  health  of  the  child.  The  exam- 
inations in  the  first  school  year  are,  therefore,  especially 
important. 

(8)  The  defect  once  discovered,  its  course  should  be 
followed  from  year  to  year.  The  child's  eye  is  a  devel- 
oping eye,  and  the  glasses,  in  many  cases,  need  to  be 
changed  occasionally. 

(9)  When  the  condition  of  the  eyes  is  such  that  sight 
is  likely  to  deteriorate  gravely  or  to  be  lost,  the  child's 
parents  should  be  fully  informed  and  the  education  of 
the  child  should  be  especially  planned  to  prepare  him 
for  this  contingency.    The  remnant  of  vision  which 
remains  should  be  utilized  in  preparation  for  the  dark- 
ness which  is  to  follow.  Special  schools  are,  therefore, 
desirable  for  the  children  who  do  not  quite  belong  in 
an  institution  for  the  blind,  but  whose  vision  is  too 


276    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

seriously  impaired  to  enable  them  to  profit  normally 
from  the  instruction  of  the  regular  class. 

(10)  The  lighting  of  the  schoolroom  is  often  far  from 
adequate.  The  light  should  amount  to  ten  meter  can- 
dles at  the  darkest  corner  of  the  room.  To  secure  this 
in  all  kinds  of  weather  and  at  all  seasons,  the  window 
space  should  ordinarily  be  not  far  from  one  fourth  of 
the  floor  space.1  The  light  should  strike  the  desk  from 
the  left  and  rear,  never  from  the  front.    Spots  and 
streaks  of  direct  sunlight  should  be  avoided.  The  ceil- 
ing should  be  almost  white  and  the  walls  a  light  buff. 
Beamed  ceilings  and  low  windows  are  never  permissible 
in  schoolrooms.   Window  shades  are  often  quite  neces- 
sary, but  they  need  to  be  managed  with  great  care  to 
prevent  streaks  of  light,  the  shutting-off  of  lights  from 
the  wrong  part  of  the  window,  too  much  darkening  of 
the  room,  etc.  They  should  be  of  linen  and  of  light  yel- 
low color.    Nothing  can  be  worse  than  the  usual 
opaque,  green  shade. 

(11)  Since  school  work,  at  best,  is  likely  to  result  in 
abuse  of  the  visual  mechanism,  special  attention  should 
be  given  to  such  matters  as  rest  periods,  size  of  hand- 
writing, the  hygiene  of  textbooks,  etc.    All  children 
should  be  taught  to  look  off  the  book  frequently.  The 
morning  session  of  three  hours  should  be  broken  by  twc 
outdoor  recesses  of  at  least  ten  minutes  each,  and  the 

1  Tests  show  that  an  average  schoolroom  in  the  central  part  of  the 
United  States  may  receive  only  about  18  per  cent  as  much  light  in 
December  as  in  June,  and  only  27  per  cent  as  much  at  4.30  P.M.  as  at 
noon. 


THE  HYGIENE  OF  VISION  277 

afternoon  session  by  at  least  one.  The  role  of  the  eye  in 
school  instruction  should  be  reduced  to  a  minimum  and 
more  effort  should  be  made  to  reach  the  mind  through 
the  ear  and  through  the  motor-activity.  It  is  the  duty 
of  the  school  to  teach  children  habits  of  economy  in  the 
use  of  the  eyes. 

Schoolbooks  should  be  made  of  white  paper,  without 
gloss;  the  lines  should  be  short  (preferably  about  three 
inches),  the  margins  wide  and  the  print  large.  The  fol- 
lowing samples,  according  to  Shaw  and  Huey,  illustrate 
the  minimum  standards  as  regards  size  of  type,  spac- 
ing, etc. 

"Then  there  is  a  turn  in  the 
road.  The  long  train  runs  over 
the  bridge  and  swings  round 
behind  a  hill. 

"The  children  cannot  see  it 
now." 

Minimum  standard  for  first  year 

(Size  of  type  at  least  2.6  millimeters  and  width  of  leading 
4.5  millimeters.) 

"  She  must  climb  the  tree.  She  held 
on,  first  to  one  branch  and  then  to  an- 
other, and  tried  to  reach  the  golden 


278    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

plums.   Her  hands,  her  face,  and  her  feet 
were  scratched  and  torn  by  the  thorns." 

Minimum  standard  for  second  and  third  years 
(Letters  not  smaller  than  2  millimeters,  with  a  leading  of 
4  millimeters.) 

"  On  the  way  down,  an  Indian  who  was  in  a 
canoe  stole  something  from  the  ship.  One  of 
the  crew  saw  the  Indian  commit  the  theft,  and, 
picking  up  a  gun,  shot  and  killed  him.  This 
made  the  other  Indians  very  angry  and  Hud- 
son had  several  fights  with  them." 

Minimum  standard  for  fourth  year 

(Letters  at  least  1.8  millimeters,  with  leading  3.6  milli- 
meters.) 

(12)  The  handwriting  should  be  large  and  oval.    In 
the  first  grades  blackboards  should  largely  replace 
book  and  pencil. 

(13)  It  is  imperative  to  remember  that  the  eye  of 
the  school  child  is  an  undeveloped  eye,  and  that  for 
this  reason  it  should  be  protected  from  overwork. 

(14)  On  leavingschool,  children  with  defective  vision 
should  have  vocational  advice.   Much  good  would  be 
done  in  such  cases  by  placing  in  the  hands  of  child  and 
parent  a  card  on  which  are  listed  the  leading  trades 
and  professions  in  order  of  their  tax  upon  vision. 

(15)  Children  whose  eyes  are  inflamed  or  discharg- 
ing, or  whose  eyelids  are  swollen  and  red,  should  be 


THE  HYGIENE  OF  VISION  279 

referred  to  the  school  physician  for  examination.  There 
are  many  cases  of  contagious  eye  disease  in  the  school, 
and  for  this  reason  the  common  towel  should  be  abol- 
ished.1 

Some  indications  of  eye  defects 

Crossed  eyes; 

Peculiar  head  postures; 

Frowning; 

Holding  book  near  the  eyes; 

Difficulty  in  reading  the  work  on  the  blackboard; 

Congested  eyes; 

"Sore  eyes,"  or  granulated  lids; 

Sensitiveness  to  light; 

Headache  (one  of  the  most  common  symptoms) ; 

Fatigue; 

Nervousness; 

Poor  spelling; 

Poor  reading  (miscalling  words,  etc.) ; 

Blurred  vision; 

Double  vision; 

Scars  on  cornea  (usually  from  ulcers) ; 

Complaints  of  seeing  colors  or  movement  of  letters  or  lines. 

SELECTED  REFERENCES' 

*1.  Frank  Allport:"  The  Eyes  and  Ears  of  School  Children."  Inter. 
Mag.  Sch.  Hyg.,  1907,  pp.  20-36. 

*2.  A.  Barrington  and  Karl  Pearson:  "A  First  Study  of  the  Inheri- 
tance of  Vision  and  of  the  Relative  Influence  of  Heredity  on 
Sight."  Eugenics  Lab.  Memoirs,  vol.  v,  1909. 

*3.  W.  H.  Burnham:  Articles  on  "Myopia,"  "Hyperopia,"  "Astig- 
matism," and  "Hygiene  of  the  Eye,"  in  Monroe's  Encyclope- 
dia of  Education.  1912. 

1  For  a  discussion  of  contagious  eye  diseases  see  Hoag  and  Ter- 
man:  Health  Work  in  the  Schools.  1914.  (Chapter  on  " Transmissi- 
ble Diseases.") 

8  For  references  which  have  chiefly  historical  value  see  Winge- 
rath:  Kurzsichtigkeit  u.  Schule.  1910,  pp.  122-27. 


280    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

4.  J.  J.  Butterworth:  "An  Analysis  of  328  Cases  of  Squint." 

School  Hygiene,  1911,  pp.  449-53. 

*5.  W.  S.  Cornell :  The  Health  and  Medical  Supervision  of  School 
Children.   1912,  pp.  201-43  and  578-84. 

6.  Auguste  Dufour:  "La  myopic  scolaire."    Third  International 
Congress  of  School  Hygiene,  1910,  pp.  618-25. 

7.  George  M.  Gould:  Biographic  Clinics,  1903  and  1904. 

8.  George  M.  Gould:  "The  Cause,  Nature,  and  Consequences  of 
Eye-Strain."  Popular  Science  Monthly,  1905,  pp.  736-47. 

9.  N.  Bishop  Harmon:  "Eyes  and  Vision  of  School  Children." 
School  Hygiene,  August,  1910. 

10.  Franz  Heilborn:  "Zur  Bekampfung  der  Schulmyopia."   Inter. 
Mag.  Sch.  Hyg.,  1910,  pp.  14-21. 

11.  Rudolf  Held:    "  Die  Kurzsichtigkeit  unter  den  Gewerbelehr- 
lingen  der  Mtinchner  Fortbildungschulen."    Zt.  f.  Schulges., 
1912,  pp.  801-06. 

*12.  E.  B.  Huey:  The  Psychology  and  Pedagogy  of  Reading.    1908. 

pp.  15-50  and  387^31. 
*13.  Edward  Jackson:  "Normal  and  Abnormal  Refractions."    In 

Randall  and  de  Schweinnitz's  American  Textbook  for  Diseases 

of  the  Eye,  Ear,  Nose  and  Throat,  pp.  212-35. 

14.  R.  Kaz :  "  L'Inspection  oculistique  des  ecoles  en  Russe,  1902- 
1912."   Inter.  Mag.  Sch.  Hyg.,  1912,  pp.  375-84. 

15.  Dr.  Franz  Krusius:  "Einige  Ergebnissen  vergleichender  Aug- 
enuntersuchung  der  hoheren  Schulen  der   Provinz   Branden- 
burg." Beiheft  sur  Zt.f.  Schulges.,  August,  1912,  pp.  95-105. 

16.  Dr.  Le  Prince:  "Myopie  scolaire;  Traitement,  Hygiene,  et 
Prophylaxie."    Third  International  Congress  of  Scfiool  Hygiene, 
1910,  pp.  604-17. 

17.  J.  M.  McCallie:  "Vision  of  Pupils  tested  by  Alphabetic  and 
Illiterate  Cards."   Psych.  Clinic,  1907,  pp.  175-82. 

18.  T.  Misawa:  "A  Few  Statistical  Facts  from  Japan."  Ped.  Sem., 
1909,  pp.  104-12. 

*19.  W.  L.  Pyle:  Personal  Hygiene.  1912  edition.   (Chapter  on  "  The 

Hygiene  of  the  Eye.") 
20.  A.  L.  Ranney:  Eye-Strain  in  Health  and  Disease,  1897,  pp. 

321. 
*21.  Edmund  Redslob:  "Volksschule  u.  Auge.  Die  Augen&rztliche 

Tatigkeit  in  den  Volksschulen  Strassburgs."   Inter.  Mag.  Sch. 

Hyg.,  1912,  pp.  336-55. 

22.  W.  H.  R.   Rivers:  "Vision."  Repts.  of  Cambridge  Anthropo- 
logical Expedition  to  Torres  Straits,  1901,  vol.  n,  part  i,  pp.  8- 
140. 

23.  Myles  Standish:  "Facts  and  Fallacies  in  the  Examination  of 
Children's  Eyes."  Proc.  N.E.A.,  1903,  pp.  1020-23. 

*24.  A.  Steiger:  "Schule  u.  Astigmatismus."  First  International 
Congress  of  School  Hygiene,  vol.  in,  pp.  483-94. 

*25.  A.  Steiger:  "Gedanken  ti.  d.  verschiedenen  Formen  der  Kurz- 
sichtigkeit." Arch.f.  Rassen  u.  Gesellschafts-Biologie,  1908,  pp. 
32-15. 


THE  HYGIENE  OF  VISION  281 

*26.  J.  Stilling:  Die  Kurzsichtigkeit;  ihre  Entstehung  w.  Bedeutung. 
Berlin,  1903. 

27.  A.  E.  Taussig:  "The  Prevalence  of  Aural  and  Visual  Defects 
among  Public-School  Children  of  St.  Louis  County,  Missouri." 
Psych.  Clinic,  1909,  pp.  149-60. 

28.  H.  True :  "  L'Eclairage  naturel  des  ecoles."   Third  Interna- 
tional Congress  of  School  Hygiene,  1910,   pp.  593-99. 

*29.  Dr.  Wingerath:  Kurzsichtigkeit  u.  Schule.   1910,  pp.  127. 
*30.  Dr.  Wingerath:   " Allmahlicher  Verlauf  der  Kurzsichtigkeit- 

bewegung  bis  zu  ihren  Wendepunkte."  Zt.  /.  Schidgti., 

pp.  321-13. 


CHAPTER  XV 

THE  HEADACHES  OF  SCHOOL  CHILDREN 

Frequency 

HEADACHES  seldom  appear  before  school  age,  but  in 
later  childhood  and  throughout  adolescence  they  are 
one  of  the  leading  symptoms  of  an  unhealthy  nervous 
condition.  The  Norwegian  Commission  of  1891  found 
occasional  or  frequent  headaches  among  27  per  cent  of 
the  children  of  the  secondary  schools,  8  to  18  years  of 
age.  The  investigations  made  in  the  same  country  by 
Hoist  and  Magelssen  ten  years  later  gave  17  per  cent. 
Hertel's  study  of  morbidity  in  the  secondary  schools  of 
Copenhagen  showed  an  average  of  about  7.5  to  14  per 
cent  of  the  boys  and  from  7  per  cent  to  30  per  cent  of  the 
girls  suffering  from  headaches,  the  proportion  for  both 
being  considerably  higher  for  the  ages  12  to  16  than 
for  any  other  years.  Schmid-Monnard's  data  for  head- 
aches and  other  nervous  states,  taken  together,  are 
presented  on  pages  383-84.  For  103,666  children  in  the 
secondary  schools  of  Russia,  Khlopine  found  a  gradual 
increase  in  frequency  of  headaches  from  6  per  cent  in 
the  lowest  grade  to  12  per  cent  in  the  seventh.  Of 
10,000  Minnesota  school  children  questioned  by  Dr. 
E.  B.  Hoag,  25  per  cent  suffered  "frequently"  from 
headache.  Among  untold  thousands  of  children  head- 
ache is  a  chronic  ailment. 


THE  HEADACHES  OF  SCHOOL  CHILDREN    283 

Causes 

The  great  excess  of  headaches  in  the  Swedish  classi- 
cal schools,  as  compared  with  schools  of  other  types  in 
the  same  country,  has  usually  been  interpreted  as  a 
direct  result  of  the  closer  application  to  books  and  the 
somewhat  longer  study  hours  of  the  classical  schools. 
This  theory,  however,  does  not  satisfactorily  explain 
the  distribution  of  headaches  in  Russian  schools  as 
shown  in  the  following  table  from  Khlopine:  — 

TABLE  29 

Per  cent  with 
Type  of  school  Number  of  pupils  headaches 

Boys'  schools  — 

(a)  Classical  44,184  8. 

(6)  Modern  language  22,539  7.9 

(c)  Technical  2,228  13.9 

Girls'  schools  44,029  11.25 

The  authors  of  the  investigations  quoted  above  are 
unanimous  in  placing  the  responsibility  for  headaches 
partly  upon  the  school,  and  the  relatively  higher  inci- 
dence which  they  have  found  in  the  upper  grades  and 
in  schools  with  the  most  difficult  programs  bears  out 
this  claim.  However,  the  investigations  in  Norway  by 
Hoist  in  1901  and  by  Magelssen  in  1904  have  given 
results  not  altogether  in  harmony  with  this  theory  (4). 
Both  these  studies  show  about  the  usual  incidence, 
varying  from  10  to  23  per  cent,  but  fail  to  show  any 
increase  in  the  higher  grades  to  correspond  with  the 
increase  in  number  of  hours  of  school  and  home  study. 
Magelssen  even  finds  a  steady  decrease  from  the  first 
to  the  fourth  grade.  This  decrease  was  also  more 
marked  for  severe  and  prolonged  headaches  than  for 


284    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

the  light  and  transitory.  It  should  be  noted,  however, 
that  the  latter  studies  were  by  no  means  so  extensive 
as  the  others.  Moreover,  Magelssen  himself  concludes 
that,  although  the  school's  responsibility  for  children's 
headaches  has  been  exaggerated,  school  life  neverthe- 
less favors  the  appearance  of  headaches  in  children  who 
are  predisposed  to  them. 

A  careful  study  of  the  most  recent  and  authoritative 
medical  literature  on  this  subject  suggests  that  the 
underlying  causes  of  headaches  are  poorly  understood; 
"shrouded  in  darkness,"  as  Magelssen  puts  it.  In  fact, 
headache  is  not  only  one  malady,  but  many,  since  it 
arises  from  a  large  variety  of  causes.  Hardly  any  organ 
of  the  body  but  may,  when  diseased,  give  rise  to  ahead- 
ache.  As  stated  by  Woods  Hutchinson  (3),  "the  head, 
in  its  vicarious  sufferings,  is  continually  doing  fire- 
alarm  duty  for  the  other  parts  of  the  body."  The  signi- 
ficance of  headaches  depends  strictly  on  the  individual 
factors  concerned  and  hardly  lends  itself  to  discussion 
in  general  terms.  In  most  cases,  however,  it  is  con- 
nected with  one  or  more  of  the  following  conditions :  — 

(1)  Anaemia.  All  the  writers  agree  that  there  exists 
a  close  connection  between  headaches  and  an  impov- 
erished condition  of  the  blood,  though  of  course  the 
two  are  not  always  associated.    Nearly  all  anaemic 
adolescent  girls   suffer   occasional   headaches,   while 
those  with  good  blood  and  habits  of  outdoor  activity 
seldom  do. 

(2)  Reflex  irritation.  This  is  one  of  the  most  import- 
ant causes,  and  includes  eye-strain,  impacted  or  carl- 


THE  HEADACHES  OF  SCHOOL  CHILDREN    285 

ous    teeth,  adenoids,  nasal  catarrh,  etc.    Eye-strain 
is  the  most  important  of  this  group. 

(3)  Toxic  conditions  of  the  blood  due  to  constipa- 
tion, recent  or  approaching  illness,  excessive  fatigue, 
etc.    Of  these,  constipation  and  the  accumulation  of 
fatigue  toxins  due  to  habits  of  inactivity  are  the  factors 
with  which  the  school  is  most  concerned.    Constipa- 
tion ranks  with  eye-strain  as  one  of  the  most  frequent 
causes  of  headaches. 

(4)  General  nervous  instability,  due  either  to  hered- 
itary or  acquired  defect  of  the  central  nervous  system. 
This  is  one  of  the  most  fundamental  factors,  and  one 
which  is  operative  to  greater  or  less  degree  in  nearly  all 
classes  of  headaches.  Neither  temporary  anaemia,  nor 
impacted  teeth,  nor  eye-strain,  nor  all  these  together 
will  necessarily  be  productive  of  headaches  in  the 
otherwise  healthy  child.  But  the  child  who  is  charac- 
terized by  general  weakness,  growth  deficiency,  or 
nervous  instability  falls  a  victim  to  headaches  from 
apparently  trivial  causes.     An  examination   of   the 
heredity  of  such  a  child  usually  brings  to  light  an  un- 
usual number  of  neurotic  tendencies  in  the  family 
stock:  migraine,  neurasthenia,  hysteria,  susceptibility 
to  shock,  etc.  Gout  and  rheumatism  are  also  frequently 
associated  with  the  neurotic  disorders.    It  is  for  this 
reason  that  headaches  are  here  classed  and  treated 
with  the  general  group  designated  as  nervous  defects, 
even  though  medical  treatises  for  the  most  part  have 
referred  only  migraine  to  strictly  nervous  causes.  The 
newer  developments  in  the  functional  aspects  of  psy- 


286    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

chopathology,  represented  by  Freud,  Jung,  Ernest 
Jones,  and  others,  are  rendering  the  once  rigid  distinc- 
tion between  nervous  and  non-nervous  headaches 
more  and  more  difficult  to  maintain. 

Migraine  is  a  headache  characterized  by  its  excru- 
ciating severity  and  by  the  physical  prostration  which 
accompanies  it,  though  it  may  not  be  as  lasting  or  as 
frequent  as  is  likely  to  be  true  of  headaches  of  other 
types.  It  is  often  preceded  by  certain  premonitory 
symptoms,  such  as  slight  dizziness,  misty  vision,  diffi« 
cult  language  articulation,  and  aphasia.  After  a  half- 
hour  or  so  these  symptoms  subside  and  the  pulsating 
throbs  of  headache  begin.  The  child  prefers  to  lie  per- 
fectly quiet  with  head  turned  from  the  light.  The  face 
is  haggard  and  the  pulse  weak.  Nausea,  sometimes  with 
vomiting,  is  common.  After  a  few  hours  the  pain  sub- 
sides, sleep  comes  on,  and  the  patient  finally  awakes 
fully  recovered,  except,  perhaps,  for  a  slight  feeling  of 
weakness  or  apathy.1  With  both  boys  and  girls,  nerv- 
ous headaches  tend  to  recur  periodically.  The  evi- 
dent hereditary  kinship  of  migraine  to  other  nervous 
diseases  throws  far  more  light  upon  its  causes  than  does 
its  occasional  association  with  eye-strain  or  toxic  con- 
ditions of  the  blood.  At  the  same  time,  there  is  no  doubt 
that  both  the  frequency  and  the  severity  of  migrain- 
ous  attacks  can  to  no  small  degree  be  controlled  by  a 
careful  hygienic  regimen,  though  not  so  completely  as 
other  types  of  headaches. 

1  See  Leonard  Guthrie,  Functional  Nervous  Disorders  of  Child- 
hood, pp.  150-52. 


THE  HEADACHES  OF  SCHOOL  CHILDREN    287 

Prevention 

In  whatever  form  the  malady  shows  itself,  the  im- 
portant thing  for  teachers  and  school  physicians  to 
understand  is  that  a  headache  means  something.  In- 
stead of  treating  the  headache,  as  such,  the  underly- 
ing causes  should  be  investigated.  It  is  well,  first,  to 
look  to  the  habits  of  life;  second,  to  the  condition  of  the 
eyes;  and  third,  for  other  unfavorable  physical  condi- 
tions and  indications  of  overpressure.  Worry,  insomnia, 
and  gastro-intestinal  disturbances  act  as  both  cause 
and  effect.  Plenty  of  exercise  in  the  open  air,  baths, 
ample  sleep,  a  well-selected  diet,  attention  to  adenoids, 
nasal  catarrh,  eye-strain,  and  defective  teeth,  coupled 
with  a  thoroughly  hygienic  school  program,  would 
probably  enable  all  but  the  most  neurotic  constitu- 
tions to  escape  the  affliction.  Headaches  are  not  made 
inevitable  by  a  bad  heredity.  In  the  schools  of  Christi- 
ania,  headaches  decreased  in  frequency  about  40  per 
cent  between  1891  and  1901,  a  fact  which  Magelssen 
thinks  is  due  entirely  to  the  introduction  of  medical 
supervision,  school  lunches,  and  a  considerably  light- 
ened program.  As  long  as  10  to  20  per  cent  of  our 
children  suffer  from  this  defect,  the  school  cannot  es- 
cape the  duty  of  using  every  available  means  to  com- 
bat it. 

REFERENCES 

*1,  S.  Briigelmann:  Die  Migrane,  Hire  Entstehung,  ihr  Wesen,  etc. 
Wiesbaden,  1909,  pp.  51. 

4.  Leonard  Guthrie:  The  Functional  Nervous  Disorders  of  Child- 
hood. 1909,  pp.  149-54. 

3.  Woods  Hutchinson:  Preventable  Diseases.  1909,  pp.  442. 
(Chapter  xvn.) 


288    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

*4.  A.  Magelssen:  "Ueber  das  Kopfweh,  —  hauptsachliche  Mi- 
grate —  an  der  Mittelschule."  Inter.  Mag.  Sch.  Eva.,  vol.  L 
1905.  pp.  285-301. 

5.  B.  K.  Rachford:  Neurotic  Ditordert  of  Childhood.   1905.  DO- 
MM* 


CHAPTER  XVI 

PREVENTIVE  MENTAL  HYGIENE* 

I.    THE   NERVOUS   CHILD 

THE  insane  population  of  the  United  States  amounts 
to  about  200,000  persons.  A  few  years  ago  most  of 
these  were  children  enrolled  in  the  public  schools,  and 
we  may  well  raise  the  question  whether  an  educational 
regime  specially  adapted  to  their  needs  could  have  pre- 
served any  considerable  proportion  of  them  from  their 
sad  fate. 

Sanity  is  a  relative  term.  Where  one  becomes  in- 
sane, a  dozen  develop  harmful  idiosyncrasies,  or  a  lack 
of  that  balance  which  characterizes  the  efficient,  reli- 
able, and  responsible  person.  Minor  mental  abnor- 
malities, far  from  being  rare,  are  seen  on  every  hand; 
excessive  irritability,  unbridled  emotionalism,  alcohol- 
ism, certain  criminal  tendencies,  obsessions,  unreason- 
able fears,  absurd  prejudices,  neurasthenia,  hysterical 
suggestibility,  etc.  Mental  balance  is  the  exception, 
not  the  rule.  Disregarding  the  inevitable  imperfec- 
tions and  minor  disharmonies  of  control,  there  are 
millions  of  people  whose  daily  behavior  does  not  justify 
a  claim  to  average  sanity.  When  our  conceptions  of 

1  The  author  is  indebted  to  Dr.  E.  B.  Huey  for  many  valuable 
suggestions  in  the  preparation  of  this  chapter. 


290    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

the  neuroses  are  sufficiently  enlarged,  they  will  include 
in  the  class  of  nervously  afflicted  a  large  proportion 
of  the  criminals,  industrial  failures,  and  other  ineffi- 
cients.  At  least  5  per  cent  of  our  school  children  are 
neurotics  in  the  sense  that  they  are  more  than  ordinar- 
ily predisposed  to  the  development  of  mental  "com- 
plexes" unfavorable  to  the  healthy  and  coordinated 
functioning  of  intellect,  emotions,  and  will. 

Some  nervous  disorders  purely  functional 

We  are  indebted  to  the  functional  point  of  view  in 
modern  psychiatry  for  opening  up  a  new  world  of  edu- 
cational principles  and  suggestions.  As  long  as  mental 
disorders  were  considered  solely  from  the  standpoint 
of  disease,  and  explanations  were  sought  purely  in 
terms  of  pathological  organic  conditions,  the  certain 
tendency  was  to  lose  sight  of  border-line  cases.  From 
this  standpoint  people  fell  definitely  into  two  classes: 
the  sane  and  the  mentally  diseased.  The  concept  of 
prophylaxis  became  narrowed  to  include  only  the 
means  of  avoiding  outright  insanity.  Even  this  kind 
of  prophylaxis,  according  to  the  fatalistic  views  which 
prevailed  until  recently  regarding  all  mental  disorders, 
had  little  room  for  influence. 

Although  a  pathological  basis  has  been  determined 
for  certain  forms  of  mental  disorder,  it  is  a  matter 
of  the  greatest  educational  significance  that  for  some 
insanities  and  for  most  of  the  minor  disturbances  of 
mental  function  no  underlying  nervous  pathology  has 
been  established.  Such  defects  are  coming  to  be  looked 


PREVENTIVE  MENTAL  HYGIENE         291 

upon  as  purely jFunctional,  by  which  is  meant  that 
they  are  the  result  of  unfortunate  emotional  experi- 
ences, unhealthy  associations  of  ideas,  defective  will- 
training,  etc. 

Especially  significant  is  the  fact  that  the  roots  of 
most  functional  mental  disorders  have  been  traced 
back  into  the  period  of  childhood.  An  initial  mental 
deviation  of  slight  extent  may  lead  ultimately  to  in- 
sanity, hysteria,  crime,  suicide,  or  a  life  of  wretched 
discontent  and  inefficiency.  The  balance  and  sanity 
of  the  adult  are  largely  predetermined  in  the  years  of 
childhood. 

From  the  functional  point  of  view,  preventive 
mental  hygiene  thus  becomes  as  broad  as  education 
itself.  It  becomes  the  duty  of  those  charged  with  the 
education  of  the  young  to  recognize  the  dangers  in- 
cident to  mental  development,  to  identify  the  child  of 
neuropathic  tendency,  and  to  throw  about  him  the 
influences  of  training  and  environment  which  will 
direct  him  into  the  paths  of  normal  thought  and  be- 
havior. It  is  necessary,  therefore,  to  pass  in  review  the 
most  common  symptoms  by  which  the  neurotic  con- 
stitution may  be  recognized. 

Symptoms  of  nervous  disorders 

It  is  understood,  of  course,  that  not  all  the  symp- 
toms enumerated  in  the  following  pages  are  found  in 
any  single  case.  Nervousness,  as  some  one  has  said, 
is  not  one  disorder,  but  a  whole  cohort.  It  may  assume 
any  one  of  many  forms,  and  the  symptoms  will  vary 


292    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

accordingly.  The  symptoms  listed  here  include  nearly 
all  of  those  commonly  seen  in  neurotic  persons. 

On  the  physical  side  the  nervous  child  is  likely  to  be 
restless,  to  lack  inhibitory  power,  to  be  easily  startled 
or  shocked,  and  to  suffer  from  muscular  twitches  or 
automatisms.  Often  there  is  a  lack  of  control  of  the  ac- 
cessory muscles,  with  stuttering,  overmobility  of  the 
facial  muscles,  nervous  fingering  of  objects,  etc.  The 
features  may  be  tense,  the  step  hurried  and  clumsy, 
the  grasp  insecure.  Pencils,  books,  and  papers  are 
dropped,  the  feet  are  shuffled,  and  the  like.  The  child 
becomes  the  despair  of  the  teacher.  When  the  arms 
are  raised  in  the  forward  position  the  fingers  either 
tremble  or  extend  themselves  with  tense  rigidity.  In- 
cob'rdinations  may  be  present,  so  that,  for  example, 
the  child  cannot  walk  with  a  book  balanced  on  the 
head.  Indigestion  is  common,  together  with  anaemia, 
deficient  or  freaky  appetite,  etc.  Often  the  heartbeat 
is  irregular  or  excitable.  The  eye  accommodation  may 
fatigue  easily,  causing  the  print  to  blur.  Headaches  are 
common. 

The  most  significant  symptoms,  however,  are  the 
emotional  and  volitional.  The  nervous  child  is  apt  to 
be  unstable  in  its  emotional  life,  easily  turned  from 
laughter  to  tears,  quick  to  anger,  irritable,  peevish,  etc. 
There  is  constant  hunger  for  excitement,  and  distrac- 
tion is  sought  in  variety  of  stimulation.  The  child  is 
not  happy  without  an  array  of  playthings  or  occu- 
pations. Numberless  idiosyncrasies  may  develop,  in- 
volving habits  of  play,  work,  dress,  eating,  etc.  The 


PREVENTIVE  MENTAL  HYGIENE          293 

eccentric  child  is  always  a  nervous  child.  Sleep  is  usu- 
ally affected.  The  child  has  difficulty  in  getting  to 
sleep,  has  to  be  tucked  in  several  times,  wakes  easily, 
has  night  terrors,  gets  up  peevish,  etc. 

The  life  of  the  nervous  child  is  often  made  wretched 
by  haunting  fears,  —  fear  of  the  dark,  of  burglars,  of 
impossible  animals,  of  death,  hell,  the  loss  of  father 
or  mother,  etc.  Sometimes  the  fear  is  not  specific,  but 
is  evident  as  a  vague  "anxiety  state"  which  makes  the 
child  forever  apprehensive.  Nervous  children  are  usu- 
ally oversensitive  to  the  opinion  of  others,  unable 
to  endure  blame,  and  constantly  hungry  for  praise. 
Severity  shatters  them,  but  for  the  sake  of  approval  or 
to  surpass  others  they  will  work  to  the  point  of  exhaus- 
tion. The  sexual  emotions  may  be  prematurely  or 
abnormally  developed.1 

Normal  conduct,  conceived  as  the  suitable  adapta- 
tion to  concrete  environment,  involves  the  highest 
of  human  powers,  and  is  the  first  to  suffer  when  the 
nervous  controls  are  weakened.  The  nervous  child  is 
hesitating,  timid,  vacillating,  unable  to  cope  with  the 
real.  More  and  more  he  falls  back  upon  day-dreams, 
books,  imaginative  enjoyments,  etc.  He  plays  little, 
adjusts  badly  to  other  personalities,  is  seldom  a  leader. 
Not  infrequently  he  is  made  an  outcast  by  his  fellow- 
pupils.  Not  being  able  either  to  mingle  on  equal  terms 

1  While  most  nervous  children  show  the  type  of  symptoms  given 
above,  certain  ones,  on  the  other  hand,  are  apathetic,  listless,  and 
indifferent.  These  limp,  over-quiet,  under-tense,  and  nervously  defi- 
cient children  are  apt  to  be  overlooked  because  they  are  facile  and 
docile. 


294    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

with  other  children  or  to  depend  on  himself,  he  clings 
to  adults  and  becomes  oldish  and  precocious. 

The  feeling  of  weakness,  distrust  of  self,  low  resist- 
ance to  fatigue,  inability  to  work  under  pressure,  diffi- 
culty in  deciding  what  to  do  next,  are  other  volitional 
symptoms  of  the  neurotic  constitution.  Work  is  al- 
lowed to  drag  along  unfinished  and  appointments  are 
not  promptly  met.  Neurotics  easily  acquire  the  habit 
of  tardiness. 

Absurd  scruples,  religiosity,  or  over-conscientiousness 
may  appear.  The  child  weeps  from  stepping  on  ants, 
considers  it  sinful  to  eat  meat,  suffers  torments  over 
imaginary  sins,  etc.  There  may  be  a  foolish  abhor- 
rence of  dirt,  so  that  the  hands  must  be  washed  dozens 
of  times  a  day.  Sometimes  the  scruples  concern  dress, 
manners,  eating,  excretory  processes,  etc. 

From  what  has  already  been  said,  it  is  clear  that 
the  moral  life  is  also  involved,  for  morality  is  nothing 
but  the  appropriate  issue  of  thought  and  emotion  in 
conduct.  The  most  common  moral  faults  of  nervous 
children  are  lack  of  self-control,  outbreaks  of  tem- 
per, incorrigibility,  stubbornness,  sulking,  egotism, 
lying,  kleptomania,  personal  vices,  etc.;  in  short, 
the  faults  that  go  with  feelings  of  weakness  and  in- 
capacity. 

The  outbreaks  are  not  so  much  due  to  the  over- 
powering strength  of  impulses  as  to  the  weakening  of 
controls.  Abnormal  stubbornness,  contrary  to  common 
opinion,  does  not  indicate  strength  of  will,  but  weakness 
and  faulty  adaptation.  Lying  is  often  a  defense  neuro- 


PREVENTIVE  MENTAL  HYGIENE         295 

sis.  The  undue  persistence  (i.e.,  beyond  ten  or  twelve 
years)  of  the  normal  childish  tendency  to  boastful, 
imaginative  lies  is  distinctly  pathological,  and  not 
infrequently  masks  a  feeling  of  weakness,  incapacity, 
inferiority,  etc.  Sometimes  it  is  a  mere  symptom  of 
abnormal  egotism.  Kleptomania  is  often  an  obsession, 
a  fixed  idea,  involving  the  collecting  instinct.  The 
most  common  moral  faults  of  the  neurotic,  however, 
are  instability,  unreliability,  and  weakness. 

Symptoms  relating  to  intelligence  are  not  as  numer- 
ous or  characteristic  as  the  emotional  and  volitional 
symptoms.  Nervous  children  are  fully  as  likely  to  be 
bright  as  dull,  but  their  intelligence  is  seldom  of  the 
most  practical  sort.  The  imagination  is  likely  to  be 
overactive.  There  is  often  an  abnormal  preoccupation 
with  books,  language,  and  abstractions  as  contrasted 
with  things.  These  traits  give  the  impression  of  men- 
tal precocity.  The  child  is  hailed  as  a  prodigy,  paraded 
as  a  genius,  etc.,  with  unfortunate  consequences  for  his 
later  development.  Some  of  the  wonder-children  are 
stupid  in  everything  except  their  exhibition  specialties. 

One-sided  development  is  favored  in  the  neurotic 
child  because  of  the  difficulty  of  giving  voluntary, 
or  forced,  attention.  Mental  association  takes  the  path 
of  least  resistance.  Extraordinary  accumulations  of 
information  alternate  with  gaps  of  profound  ignorance. 
Day-dreaming  and  intellectual  indolence  take  the  place 
of  determined  attack  upon  the  varied  intellectual 
problems  set  by  the  school  or  environment.  Periods 
of  intense  intellectual  activity  may  occasionally  super- 


296    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

vene,  followed  by  slumps  that  may  be  characterized 
as  "twilight  states."  Comprehension  is  uneven. 

Suggestibility,  often,  is  abnormal.  The  child  imi- 
tates the  peculiar  gestures  of  those  he  admires.  Stutter- 
ing and  even  choreiform  movements  are  sometimes 
initiated  in  this  way.  The  organization  of  their  ideas 
may  be  unduly  influenced  by  accidental  stresses.  In- 
stability characterizes  the  intellectual  as  well  as  the 
emotional  and  volitional  life.  The  neurotic  child  is  the 
creature  of  his  environment.1 

The  picture  may  be  made  more  clear  by  the  follow- 
ing description  of  a  concrete  case :  — 

Girl,  aged  7.  Weight  and  height  normal  for  age.  Bright 
and  highly  imaginative.  Two  years  advanced  in  school. 
Speech,  blustering,  with  hasty  and  indistinct  articulation 
which  months  of  daily  drill  failed  to  improve.  Finical  in  her 
habits.  Has  an  unconquerable  preference  for  stimulating 
and  highly  seasoned  foods,  pickles,  salt,  spices,  cakes,  coffee, 
hot  soups,  etc.  Seldom  eats  the  more  wholesome  articles  of 
food  except  under  compulsion.  Almost  from  babyhood  has 
had  an  abnormal  interest  in  dress.  Plans  for  weeks  ahead 
the  apparel  for  set  occasions.  Absurdly  preoccupied  with 
ceremonies  and  symbolisms  relating  to  birthday,  Christmas, 
Easter,  etc.  All  such  occasions  are  planned  for  in  the  minut- 
est detail.  Her  life  is  pathologically  subjective  and  intro- 
spective. Volatile,  cries  at  slightest  censure,  fishes  for  praise. 
Is  oversensitive  to  the  good  will  of  the  teacher  and  over- 
works at  school  from  emulation.  Over-affectionate,  yet 
imperious  and  hard  to  manage.  Unreliable,  "forgets" 
promises.  Sleeps  poorly,  has  nightmares,  wakes  easily  and 
cannot  get  to  sleep  again  for  hours.  Obsessive  fears  make 
her  miserable  as  night  approaches.  She  cannot  go  to  sleep 
1  See  Hysteria. 


PREVENTIVE  MENTAL  HYGIENE         297 

without  a  light  in  the  room  and  some  one  beside  the  bed. 
The  bed  must  be  against  the  wall,  the  doors  shut  and  locked, 
etc.  She  is  tormented  with  religious  and  moral  scruples. 
Worries  if  prayers  are  forgotten,  and  cannot  bear  the  thought 
of  missing  Sunday  School.  Suffers  from  headaches,  anaemia, 
and  constipation.  Gestures  are  awkward  and  exaggerated. 
Always  fingering  objects.  Fumbles  and  drops  things. 

Suggestions  for  observation l 

I.  Disturbances  of  motor-control. 
Overmobility  of  facial  muscles. 
Twitching  of  eyelids,  face,  or  fingers.  (Test  control 

of  fingers  by  having  children  close  the  eyes  and 

sit  with  hands  extended,  palms  down,  on  the 

desk.) 

Spasmodic  movements  of  any  kind. 
Bad  coordination.  (See  if  child  can  walk  with  book 

balanced  on  the  head.) 
Drops  objects  frequently  from  the  hands. 
Jerky  handwriting. 
Inability  to  sit  still.    (Ask  children  to  sit  still  for 

five  minutes.) 
Stuttering. 

Blustering,  rapid  speech. 

Nail-biting,  chewing  pencil,  fumbling  a  button,  etc. 
Bed-wetting. 

Frequent  requests  to  go  out. 
II.  Emotional  and  moral  disturbances. 
Irritability  or  bad  temper. 
Laughs  or  cries  at  slight  cause. 
Undue  emotion  of  any  sort. 
Extreme  suggestibility. 
Excessive  timidity  or  embarrassment. 

1  The  writer  is  here  indebted  to  Cornell's  Health  and  Medical 
Inspection  of  School  Children,  pp.  333-34,  and  to  Dr.  E.  B.  Hoag. 


298    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

Misbehavior. 

Sex  perversions. 

Perverted  tastes. 

Moroseness,  sullenness,  or  obstinacy. 

Over-affectionateness. 

Undue  sensitiveness  to  praise  or  blame. 

Over-conscientiousness. 

Religiosity. 

Day-dreaming. 

Lying  or  stealing  (if  moral  environment  is  good). 

Cruelty. 

Finical  habits. 

Eccentricity  or  "queerness." 

Child  an  "outcast"  among  his  fellows. 

Sleep  disturbed  (nightmares,  tooth-grinding,  sleep- 
walking, etc.). 

Morbid  fears. 

Chronic  uneasiness  or  apprehension. 
HI.  Indications  of  nervous  exhaustion. 

Apathy. 

Dull  eyes. 

Drooping  shoulders. 

Slouching  postures. 

Shuffling  gait. 

Arms  and  hands  droop  when  extended  forward. 
IV.  Associated  physical  conditions. 

Adenoids. 

Eye-strain. 

Headaches. 

Faintness  or  dizziness. 

High  fatiguability. 

Poor  nutrition. 


CHAPTER  XVH 

PREVENTIVE  MENTAL  HYGIENE 
H.   COMMON  NEUROSES  OF  DEVELOPMENT 

Psychasthenia 

ACCEPTING  Janet's  conception  of  psychasthenia,  we 
may  define  the  condition  as  one  of  chronic  uneasiness 
and  disquiet,  with  feelings  of  incompleteness.  Obses- 
sions, impulsions,  lack  of  certitude,  anxiety,  timidity, 
longing  for  moral  support  and  comfort,  meekness, 
indecision,  etc.,  are  the  most  common  symptoms.  If 
extreme  fatiguability  is  present  as  one  of  the  main 
symptoms  the  condition  is  known  as  neurasthenia.1 
The  symptoms  may  include  any  or  all  of  the  long  list 
given  in  the  preceding  pages  as  characteristic  of  the 
neurotic  constitution.  Visceral  disturbances,  disorders 

1  Psychasthenia  and  neurasthenia  are  variously  defined  by  differ- 
ent authors.  Janet  states  that  they  are  "  two  manifestations  of  dif- 
ferent degree  and  gravity,"  of  which  "neurasthenia  is  the  initial 
form."  Neurasthenia,  says  Janet,  is  essentially  "  an  organic  enfeeble- 
ment"  marked  by  bodily  symptoms,  such  as  weakness,  trembling, 
digestive  troubles,  and  the  like.  Visceral  disturbances  are  especially 
common.  In  psychasthenia  the  disturbances  present  themselves 
more  especially  in  the  conscious  mental  life.  "Psychasthenia  is  a 
depressive  psycho-neurosis  characterized  by  diminution  of  the  func- 
tions which  permit  us  to  act  on  reality  and  to  perceive  the  real,  by 
the  substitution  of  mental  operations  that  are  inferior  and  exagger- 
ated, under  the  form  of  doubts,  of  agitations,  and  of  anxieties,  and  by 
obsessive  ideas  which  express  the  preceding  troubles  and  which  them- 
selves express  the  same  character."  (Lea  Obsessions  et  la  Psychaa- 
thenie,  vol.  i,  pp.  754-55.) 


300    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

of  nutrition,  headaches,  insomnia,  constipation,  ver- 
tigo, muscular  weakness,  etc.,  are  a  few  of  the  many 
symptoms  likely  to  be  associated  with  it. 

Psychasthenia  is  common  among  adults,  but  is  sel- 
dom met  with  among  children.  A  considerable  propor- 
tion of  teachers  are  affected,  probably  3  to  5  per  cent. 
According  to  Ballet  (1)  it  is  most  common  among  busi- 
ness men,  teachers,  and  students,  and  least  among 
laboring  men,  the  clergy,  farmers,  and  physicians. 
More  women  than  men  are  subject  to  it. 

Until  recently  medical  authorities  endeavored  to 
explain  psychasthenia  in  terms  of  physical  causation, 
such  as  chronic  exhaustion  of  the  central  nervous  sys- 
tem due  to  overwork,  or  a  condition  of  auto-intoxi- 
cation resulting  from  infectious  diseases,  glandular 
disorders,  etc.  Adolescent  overpressure  was  thought  to 
play  a  great  part. 

It  is  now  generally  believed  that  psychasthenia  may 
be  of  functional  origin,  a  result  of  the  interplay  be- 
tween a  somewhat  unstable  heredity  and  certain  ele- 
ments of  an  unsuitable  training.  Over-repression  is  one 
of  these.  The  functional  view  is  supported  by  the  fact 
that  a  psychoanalytic  search  for  the  causes,  followed 
by  reeducation  of  the  patient  along  the  lines  of  his 
mental  faults,  often  brings  a  cure.  The  methods  of 
Christian  Science,  Yoja  practice,  etc.,  sometimes  ac- 
complish this  result  in  an  unscientific  way;  the  trained 
psychiatrist  succeeds  through  his  knowledge  of  under- 
lying psychological  principles. 

From  the  functional  point  of  view,  childhood  is  the 


PREVENTIVE  MENTAL  HYGIENE         301 

critical  period  for  those  of  psychasthenic  tendency.  A 
training  which  inculcates  over-conscientiousness  and 
scrupulosity,  which  destroys  self-confidence  and  initi- 
ative, or  fails  to  develop  a  rich  fund  of  healthful,  objec- 
tive interests,  lays  the  foundation  for  the  pathological 
timidity,  indecision,  weakness,  anxieties,  and  morbid 
fears  characteristic  of  psychasthenia.  Interesting  illus- 
trative cases  are  described  by  Dr.  Williams  (60). 

(1)  A  boy,  reproved  severely  by  his  puritanical  parents 
for  jealousy  of  his  little  brother,  developed  chronic  mental 
distress,  the  mania  for  touching  things  (dSlire  de  toucher), 
and  was  a  slave  to  the  apparently  absurd  impulse  to  lie  down 
on  his  back  several  times  when  putting  on  his  clothes.    In- 
vestigation brought  out  the  fact  that  these  were  childish 
devices  for  expiation  for  the  sin  of  jealousy. 

(2)  A  girl  of  eight  years  was  brought  to  Dr.  Williams 
because  of  involuntary  facial  grimaces  and  foolish  gestures, 
such  as  touching  the  floor  before  she  stepped  on  it.  The  girl 
had  been  severely  trained,  particularly  along  the  line  of 
avoiding  injury  to  others.     Questioning  revealed  that  the 
child  had  worried  for  fear  her  expired  breath,  which  she  had 
been  taught  was  poisonous,  might  do  injury  to  others.   The 
facial  grimaces  were  discovered  to  be  kissing  movements, 
since,  from  her  childish  way  of  thinking,  kissing  each  breath 
of  expired  air  would  "make  it  well."   The  touching  of  wood, 
likewise,  was  the  "healing  touch"  that  would  keep  it  from 
being  hurt  by  her  tread. 

(3)  Affectionate  girl  with  parents  of  cold,  nagging  dis- 
position, who  did  not  permit  in  her  any  show  of  affection. 
The  child  developed  insomnia,  headache,  dizziness,  habits 
of  crying,  etc.   Reform  of  the  parents  brought  relief  to  the 
child. 

Williams  concludes  that  the  moral  sanctions  suit- 


302    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

able  for  adults  may  be  decidedly  injurious  to  children. 
Coupled  with  puritanical  over-repression,  they  tend  to 
develop  obsessions  and  anxieties,  the  mania  to  com- 
pensate, to  expiate,  to  make  contracts  with  Fate,  etc. 
Let  us  avoid  moral  over-pressure  by  not  taking  the 
faults  of  the  child  too  seriously  and  by  holding  him  to  a 
standard  of  conduct  commensurable  with  his  imma- 
turity. 

Hysteria 

Hysteria  is  essentially  an  enfeeblement  of  mental 
control,  of  the  synthesizing,  organizing,  and  directive 
powers  of  the  mind.  This  lowering  of  what  Janet  calls 
the  "psychic  tension"  permits  emotional  shock  or 
strain  to  start  dissociation,  or  mental  cleavage.  Cer- 
tain thought-systems  drop  out  of  consciousness,  or  are 
banished  because  of  their  disagreeable  emotional  tone. 
Queer  and  inefficient  "substitutions"  then  take  the 
place  of  the  lost  thought-systems,  the  substitutions 
being  themselves  the  symptoms  of  the  disorder. 

The  symptoms  are  marked  by  abnormal  suggesti- 
bility, dominance  of  automatisms,  dreamy  states,  etc., 
and  may  include  all  sorts  of  motor  and  sensory  disturb- 
ances, such  as  convulsions,  tremors,  paralyses,  vaso- 
motor  and  secretory  disorders,  anaesthesias,  hyperaes- 
thesias  (under-sensitivity  and  over-sensitivity),  etc. 
Pin-pricks  in  certain  localities  may  not  be  felt.  The 
visual  field  may  be  retracted  in  one  or  both  eyes,  and 
numerous  other  symptoms  of  similar  nature  may  ap- 
pear without  any  real  physical  disability  underlying 
them.  The  disorder  is  purely  functional. 


PREVENTIVE  MENTAL  HYGIENE          303 

True  hysteria  does  not  often  develop  earlier  than  15 
to  18  years,  but  authorities  are  agreed  that  the  mental 
conditions  which  lead  to  the  hysterical  manifestations 
have  their  origin  in  the  first  fifteen  years  of  life.  Hys- 
teria is  always  predetermined  in  the  school  period  or 
in  the  period  immediately  preceding  school  life. 

The  characteristic  trait  of  those  hysterically  in- 
clined is  abnormal  suggestibility,  together  with  emo- 
tional instability.  The  "railroad-wreck"  spine  illus- 
trates very  well  the  mental  mechanism  of  one  form  of 
hysteria.  A  young  woman  is  thrown  from  her  seat  in  a 
collision  of  trains.  She  is  picked  up  unable  to  walk 
and  carried  to  the  hospital.  Although  the  most  careful 
diagnosis,  including  the  radiograph,1  reveals  no  injury 
whatever  to  spine  or  hips,  the  patient  may  remain  for 
months  in  a  paralyzed  or  semi-paralyzed  condition. 
There  may  be  no  conscious  intent  to  deceive  or  simu- 
late in  order  to  secure  damages,  get  sympathy,  etc.; 
the  case  is  due  entirely  to  suggestion.  Chorea,  deaf- 
ness, speech  defects,  asthma,  and  many  other  disorders 
are  sometimes  of  hysterical  origin.  It  is,  therefore, 
always  a  problem  to  distinguish  true  chorea,  real 
organic  deafness,  etc.,  from  their  hysterical  simula- 
tions. 

School  epidemics  of  various  kinds  of  psychical  con- 
tagion have  their  origin  in  the  hysterical  predisposi- 
tion. Of  several  such  epidemics  described  in  the  inter- 
esting study  of  Dr.  Burnham  (4)  one  or  two  may  be 
quoted  here. 

1  X-ray  pictures. 


804    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

(1)  The  Liegnitz  epidemic. 

One  of  the  earliest  reported  epidemics  of  this  kind  oc- 
curred in  Gross-tinz,  near  Liegnitz,  Germany,  in  1892.  The 
first  case  appeared  on  the  28th  of  June,  when  a  ten-year-old 
girl,  without  apparent  occasion,  began  all  at  once  to  tremble 
in  her  right  hand  and  then  gradually  hi  the  whole  body,  a 
condition  which  passed  off  in  about  half  an  hour  without  any 
further  results.  On  the  next  day  the  trembling  appeared  in 
several  other  girls,  and  lasted  from  half  an  hour  to  an  hour. 
Not  the  children  sitting  next,  but  those  several  seats  away, 
were  affected.  The  trembling  returned  regularly  each  day  and 
began  to  last  longer  and  longer,  and  the  school  instruction 
soon  suffered  because  the  girls  who  were  attacked  could  not 
write.  One  day,  at  the  beginning  of  July,  one  of  the  trem- 
bling girls  was  attacked  with  convulsions  and  fell  under  the 
seat.  Although  the  teacher  immediately  removed  this  child 
from  the  class,  several  new  cases  of  convulsions  soon  appeared 
among  the  healthy  girls,  and  on  the  19th  of  July  the  number 
of  victims  was  twenty.  During  the  period  from  the  14th  to 
the  20th  of  July,  the  instruction  was  equally  exciting  for 
both  teacher  and  pupils,  and  presented  a  noteworthy  picture 
to  the  medical  observer.  On  almost  every  seat  were  patients 
having  convulsions  of  the  whole  body.  The  girls  fell  under 
the  seats  and  had  to  be  carried  from  the  room  by  the  boys, 
and  the  attacks  continued  for  different  periods  of  time  be- 
tween a  quarter  of  an  hour  and  an  hour,  when  they  gradu- 
ally ceased.  After  the  autumn  vacation  the  attacks  ceased 
and  no  fresh  cases  were  reported. 

(2)  In  October,  1905,  a  thirteen-year-old  girl  in  Meissen 
was  attacked  with  a  tremor  or  shaking  of  the  hands.    Soon 
other  cases  appeared,  and  although  it  was  hoped  that  the 
trouble  would  disappear  during  the  Christmas  vacation,  this 
did  not  happen,  but  in  January  and  February  the  disease 
became  epidemic,  and  by  the  21st  of  February,  134  children 
were  afflicted.  The  classes  were  then  closed  until  the  14th  of 


PREVENTIVE  MENTAL  HYGIENE         305 

March,  and  the  parents  were  given  advice  in  regard  to  the 
treatment  of  the  children.  In  spite  of  this,  the  number  in- 
creased. On  the  20th  of  March,  237  children  were  suffering 
from  the  disorder.  Then  the  number  began  to  decrease,  and 
on  the  29th  of  March  there  were  only  196  afflicted,  and  by 
the  17th  of  May  the  epidemic  seems  to  have  been  at  an  end. 
The  disease  was  caused  by  seeing  a  child  who  had  it;  and 
children  from  all  classes,  strong  and  weak,  were  attacked, 
•especially  the  girls.  The  causal  factor  must  have  been  psy- 
chic infection.1 

Children  should  never  be  punished  or  blamed  for 
such  hysterical  symptoms,  nor  should  their  attention 
be  needlessly  directed  toward  their  disorder.  There 
may  be  no  conscious  pretension  on  the  child's  part. 
The  special  class  has  been  used  to  advantage  in  such 
epidemics  to  prevent  the  spread  of  the  contagion,  and 
soon  brings  about  a  cure  of  those  already  afflicted. 
The  Basel  special  class  of  1904,  organized  for  this  pur- 
pose, went  on  with  the  regular  school  work,  and  by 
means  of  suggestive  treatment  applied  in  the  form  of 
simple  gymnastic  exercises,  warm  lunches,  etc.,  all  the 
cases  were  speedily  cured. 

Real  hysteria  is  not  extremely  common,  but  the 
emotional  instability  and  the  hyper-suggestibility 
bordering  on  hysteria  are  not  uncommon.  To  fixate 
the  child's  attention  too  intently  upon  matters  of 
health,  to  over-stimulate  the  precocious,  to  permit  day- 
dreaming to  take  the  place  of  productive  work,  to 
destroy  in  any  way  the  feeling  of  self-reliance  and  per- 

1  Epidemics  of  hysteria  are  of  course  extremely  rare.  They  are 
instructive,  however,  because  they  illustrate  the  possible  force  ol 
that  psychic  contagion  which  in  milder  form  is  known  to  every  one. 


806    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

sonal  independence,  all  help  in  the  formation  of  char- 
acters that  may  become  hysterical.  To  enter  into  the 
"league  of  silence"  regarding  sexual  matters  and  to 
conceal  from  the  child  the  knowledge  of  sex  demanded 
by  a  normal  curiosity  leads  to  the  acquisition  of  all 
kinds  of  false  notions  and  to  "modes  of  repressions 
and  concealments  of  emotional  states  which  may  be- 
come the  nuclei  for  hysterical  manifestations  in  later 
life"  (13). 

Dementia  prcecox 

Dementia  prsecox  is  one  of  the  most  interesting 
forms  of  insanity  for  several  reasons.  In  the  first  place, 
it  is  extremely  common,  accounting  for  some  30  per 
cent  of  the  total  admissions  to  insane  hospitals.  In  the 
second  place,  it  does  not  attack  the  old  or  mentally 
decrepit,  but  the  youth,  and  quite  frequently  the  youth 
of  marked  intellectual  promise.  In  the  third  place,  the 
newer  studies  of  the  disease  show  that  it  is  probably 
due  in  most  cases  to  definite,  ascertamable  functional 
disturbances  of  the  individual's  mental  evolution,  and 
that,  if  taken  in  hand  early  enough,  it  will  yield  to  the 
right  kind  of  educational  treatment.  In  the  fourth 
place,  the  methods  which  have  been  successfully  used 
in  its  prevention  and  treatment  throw  a  flood  of  light 
on  preventive  mental  hygiene  in  general.  The  lesson  it 
teaches  forms  a  contribution  of  real  value  to  the  prob- 
lem of  education  for  efficient  living. 

Dementia  prsecox  is  a  form  of  adolescent  insanity 
which  usually  involves  fantastic  day-dreaming,  sexual 
imagination,  brooding  over  disappointments,  and  (the 


PREVENTIVE  MENTAL  HYGIENE         307 

most  central  symptom)  a  discrepancy  between  thought 
and  action.  As  described  by  Jelliffe  (26),  it  is  most 
likely  to  develop  in  those  "who  are  abnormally  bril- 
liant, but  whose  lights  are  turned  inward."  The  pa- 
tient may  be  gentle  hi  disposition;  of  dreamy,  lofty, 
exclusive,  disdainful  demeanor;  conceited,  egotistic, 
given  to  deep  ruminations,  and  always  unpractical. 
"There  is  a  glorification  of  vague  abstractions" 
coupled  with  "a  constitutional  aversion  to  deeds."  As 
characterized  by  Dr.  Meyer  (40),  it  is  essentially  "a 
miscarriage  of  instincts  through  lack  of  balance";  a 
deterioration  of  habits  "due  to  progressively  faulty 
modes  of  behavior  and  action";  "a  covering-up  rather 
than  a  correction  of  harmful  yearnings."  In  the  classi- 
cal description  of  Dr.  Meyer,  "There  develops  an  insid- 
ious tendency  to  substitute  for  an  efficient  way  of  meet- 
ing difficulties  a  superficial,  moralizing  self-deception, 
and  an  uncanny  drift  into  many  varieties  of  shal- 
low mysticism  and  metaphysical  ponderings  or  into 
fantastic  ideas  which  cannot  possibly  be  put  to  the  test 
of  action.  All  this  is  at  the  expense  of  really  fruitful 
activity,  which  tends  to  appear  insignificant  to  the 
patient  in  comparison  with  what  he  regards  as  far 
loftier  achievements.  Thus  there  develops  an  ever- 
widening  cleavage  between  mere  thought-life  and  the 
life  of  actual  application,  such  as  would  bring  with  it 
the  corrections  found  in  concrete  experience.  Then, 
under  some  strain  which  a  normal  person  would  be 
prepared  for,  a  sufficiently  weakened  and  sensitive 
individual  will  react  with  manifestations  which  con- 


BOS    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

stitute  the  disorders  of  the  so-called  'deterioration 
process,'  or  dementia  praecox.  Unfinished  or  chronically 
sub-efficient  action,  a  life  apart  from  the  wholesome 
influence  of  companionship  and  concrete  test,  and 
finally  a  progressive  incongruity  in  meeting  the  inev- 
itably complex  demands  of  the  higher  instincts  —  this 
is  practically  the  formula  for  the  deterioration  process." 
The  following  are  clinical  descriptions  of  typical 
cases,  the  first  from  Dr.  Meyer,  the  second  from  Dr. 
Hoch:  — 

(1)  She  began  school  at  seven  years,  was  smart,  and 
applied  herself  well,  but  at  the  age  of  eleven  she  seemed  to  be 
failing,  and  was  thought  to  be  studying  too  hard.  She  grew 
thin,  seemed  nervous,  and  complained  of  headaches;  at 
twelve  she  was  in  poor  health.  .  .  .  [Later]  She  was  disap- 
pointed at  home,  for  some  time  dreamt  of  becoming  a  teacher, 
but  soon  sank  into  hypochondriacal  ruminations,  and  fin- 
ally, at  twenty-one,  after  useless  surgical  operations,  passed 
into  a  confused  religious  excitement,  followed  by  stupor,  in 
which  she  sits  inactive  and  irresponsive,  with  the  top-heavy 
and  yet  empty  notion  of  being  good,  of  saving  the  world,  etc. 

(2)  The  patient  is  said  to  have  been  retiring,  modest,  shy; 
had  to  be  driven  to  play.    The  parents  say  that  the  other 
child  they  have  is  aggressive,  while  the  patient  is  not;  that 
the  other  looked  out  for  herself,  while  the  patient  relied  on 
others.  She  was  always  afraid  she  had  not  done  things  right. 
.  .  .  When  thirteen,  she  became  inactive,  lost  interest,  be- 
came dissatisfied  with  things,  got  rattled  at  school  and  could 
not  do  her  work.  Then  followed  vague  talk  about  deep  sub- 
jects, such  as  "Why  does  the  universe  exist?"  and  so  on. 
By  fifteen  she  was  gravely  deteriorated. 

The  next  few  decades  may  witness  the  complete 


PREVENTIVE  MENTAL  HYGIENE         309 

demonstration  that  such  cases  can  usually  be  saved  by 
being  taken  early  in  hand  and  trained  to  more  com- 
plete activity  and  appropriate  self-objectification. 

But,  as  already  indicated,  the  importance  of  this 
principle  of  the  sanifying  influence  of  wholesome  ac- 
tivity does  not  lie  merely  in  the  insurance  it  offers 
against  insanity.  Inasmuch  as  sanity  is  purely  a  rela- 
tive term,  the  importance  of  activity  and  self-objecti- 
fication goes  far  beyond  its  prophylactic  value  as  an 
insurance  against  admission  to  an  insane  hospital.  In  a 
sense  no  one  is  perfectly  sane.  Just  as  there  are  millions 
of  physically  inefficient  persons  who  are  in  no  immedi- 
ate danger  of  death,  and  relatively  few  who  are  perfect 
of  body,  so  there  are  numberless  people  who  are  in  no 
danger  of  trial  for  lunacy,  but  who,  nevertheless,  are 
decidedly  below  their  best  level  of  mental  balance. 
Dementia  prsecox  has  been  mentioned  at  length  only 
because  it  reveals,  writ  large,  that  which  to  a  less  de- 
gree is  true  of  most  of  us.  The  causes  which  produce 
complete  deterioration  in  the  individual  of  nervous 
instability  may,  in  the  person  of  better  hereditary 
endowment,  result  in  nothing  more  serious  than  a  tem- 
porary nervous  breakdown,  "a  slump  of  relative  inac- 
tivity," or  some  other  manifestation  tending  to  rob 
life  of  its  zest  and  render  success  more  difficult. 

In  order  to  escape  such  dangers,  children  need  to  be 
taught  to  "  avail  themselves  of  the  power  of  the  con- 
crete." School  work  should  feed  the  instinct  of  work- 
manship instead  of  starving  it.  As  Meyer  states  it, 
"If  the  school  gave  more  opportunity  for  doing  things, 


310    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

dreams  of  doing  would  be  less  tempting."  It  behooves 
us  "to  make  doing  just  as  attractive  as  knowing,"  and 
to  explore  ways  and  means  of  enlarging  the  child's 
opportunities  for  the  accomplishment  of  simple,  whole- 
some, and  enjoyable  things.  Plays  and  games  which 
demand  quick  decision  and  self-reliance  are  indispens- 
able to  a  well-balanced  mental  development.  Good 
players  seldom  become  "queer"  or  socially  inefficient. 
We  must  find  for  each  child  the  level  where  he  can 
function  successfully  if  we  would  have  him  escape  the 
shocks  of  disappointment,  the  habits  of  failure,  and  the 
resulting  inactivity,  day-dreaming,  vain  wishing,  and 
the  chasm  between  thinking  and  doing.  If  we  will  only 
take  pains  to  fit  the  tasks  to  the  capacity,  every  child 
can  be  taught  to  do  certain  things  well  and  to  take 
pleasure  in  doing  them.  Nothing  is  more  subversive  of 
sanity  than  a  regime  of  inactivity  and  repression  which 
creates  a  smouldering  volcano  of  sentiment  and  frothy 
desire. 

Chorea  (St.  Vitus's  dance) 

In  a  majority  of  cases  chorea  is  associated  with  rheu- 
matic affections  of  the  joints,  "growing-pains,"  etc., 
though  in  all  probability  it  presupposes  also  the  neu- 
rotic constitution.  The  onset  often  seems  to  be  occa- 
sioned by  overwork,  excitement,  shock,  and  the  like, 
and  it  is  certain  that,  notwithstanding  the  connection 
with  rheumatism,  a  certain  proportion  of  cases  could 
be  prevented  by  suitable  mental  hygiene.  Rheumatic 
symptoms  in  children  not  characterized  by  nervous 
instability  are  not,  as  a  rule,  followed  by  chorea. 


PREVENTIVE  MENTAL  HYGIENE         311 

Chorea  is  by  no  means  an  uncommon  disease,  affect- 
ing probably  about  one  child  out  of  a  hundred  some- 
time during  the  school  life.  It  seldom  appears  before 
the  age  of  6  and  not  often  after  14.  Of  2000  cases  ana- 
lyzed by  Starr  45  per  cent  began  between  6  and  10,  38 
per  cent  between  11  and  15.  It  occurs  more  of  ten  in 
the  spring  months.  Girls  are  affected  much  more  often 
than  boys,  according  to  Still  (48),  in  the  ratio  of  about 
5  to  2.  The  choreic  child  is  usually  bright,  often  pre- 
cocious and  of  excitable  temperament  —  exactly  the 
child  who  is  most  likely  to  be  spurred  on  to  rapid 
school  progress  and  who  is  most  likely  to  be  injured 
by  it. 

The  duration  of  the  disease  is  usually  from  six  weeks 
to  three  months,  though  a  few  cases  drag  on  with  little 
change  for  years.  Because  of  the  connection  with 
rheumatism  the  heart  is  very  likely  to  be  affected. 
Dr.  Still  found  heart  symptoms  in  155  out  of  250  cases. 
Many  adults  who  suffer  from  organic  heart  disease 
are  merely  victims  of  a  neglected  rheumatic  infection 
during  childhood.  On  account  of  the  danger  of  heart 
involvement,  as  well  as  for  the  needed  mental  rest,  it  is 
very  important  that  chorea  be  diagnosed  in  its  earliest 
stages,  and  that  the  child  be  taken  from  school  at  once 
and  put  to  bed.  Absolute  rest  in  bed  is  always  advis- 
able for  a  period  of  from  three  to  six  weeks,  and  school 
work  should  not  be  taken  up  for  several  months.  Re- 
currences are  very  common,  especially  in  the  spring 
months,  and  all  authorities  are  agreed  that  nothing  is 
so  likely  to  determine  a  fresh  attack  as  the  too  early 


312    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

return  to  school.  An  additional  reason  for  keeping  the 
child  out  of  school  until  all  symptoms  have  disap- 
peared is  the  danger  of  psychic  contagion.  Veritable 
school  epidemics  of  chorea  have  been  recorded. 

Every  teacher,  therefore,  should  know  the  symp- 
toms of  beginning  chorea.  The  disease  generally  ap- 
pears so  gradually  that  the  child  is  likely,  to  its  great 
injury,  to  be  allowed  to  continue  in  school  for  two 
or  three  weeks,  or  longer,  after  it  has  begun  to  de- 
velop. 

At  first  the  child  may  be  considered  unusually  nerv- 
ous. It  drops  things,  has  difficulty  in  sitting  still,  is 
clumsy  in  eating  or  buttoning  the  clothes,  has  an  awk- 
ward, shuffling,  unsteady  gait,  and  stumbles.  Some- 
times the  first  symptoms  are  slight  spasms  of  the  facial 
muscles,  twitching  of  the  eye,  grimaces,  and  the  like. 
Later  the  movements  become  intensified,  irregular, 
jerking,  and  almost  constant  except  during  sleep.  In 
severe  cases  speech  is  almost  impossible,  and  the  child 
may  be  practically  unable  to  walk  or  to  handle  fork  or 
spoon  in  eating.  The  mental  symptoms  of  chorea  are 
often  almost  as  characteristic  as  the  physical.  The 
child  is  irritable,  emotional,  capricious,  inclined  to 
worry,  sleeps  badly,  has  nightmares,  headaches,  and  a 
poor  appetite.  Blood  examinations  nearly  always  show 
profound  disturbances  of  nutrition.1 

When  fully  developed,  the  disease  is  not  easily  mis- 
taken for  any  other  nervous  affection  except  habit- 

1  The  rheumatic  infection  is  thought  to  bring  about  the  rapid 
destruction  of  red  blood  corpuscles. 


PREVENTIVE  MENTAL  HYGIENE         313 

spastn,  and  this  distinction  may  usually  be  made  with- 
out difficulty  if  it  is  remembered  that  habit-spasm 
is  always  quite  definitely  located  in  certain  muscles, 
while  the  movements  of  chorea  are  irregular  and  more 
generally  distributed.  You  can  describe  the  movements 
of  habit-spasm,  get  a  definite  picture  of  them,  but  you 
can  seldom  tell  what  twitchings  or  grimaces  the  choreic 
child  will  perform  next. 

It  is  the  early  symptoms  especially  with  which  the 
teacher  should  try  to  familiarize  herself,  the  slight 
awkwardness,  twitchings,  unrest,  peevishness,  excita- 
bility, thickness  of  the  tongue,  etc.  As  a  rule  the  child 
is  scolded  or  punished  at  home  and  at  school  for  a  week 
or  two  after  the  disease  is  under  headway.  It  is  useless 
to  expect  the  average  parent  to  make  the  diagnosis  in 
the  early  stages,  but  teachers  with  their  larger  oppor- 
tunities for  observing  children  may  learn  to  do  so  if 
they  are  at  all  observant. 

Tics,  habit-spasms,  etc. 

These  are  forms  of  spasmodic  movements  which 
shade  into  one  another  and  are  sometimes  difficult  to 
differentiate  from  chorea.  Tics  and  habit-spasms  in- 
volve an  isolated  twitching  or  contraction  of  any 
muscle  or  muscle-group,  as  of  the  face,  tongue,  neck, 
or  organs  of  respiration,  such  as  elevating  the  lip  to 
meet  the  nose,  sniffling,  lightning-like  blinks  or  nods, 
writhing,  shrugging  the  shoulders,  elevating  the  chin 
and  stretching  the  neck,  protruding  the  tongue,  show- 
ing the  teeth,  emitting  queer  guttural  noises,  etc.  The 


314    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

movements  may  be  confined  to  one  muscle,  or  muscle- 
group,  or  there  may  be  a  whole  repertoire  of  foolish- 
looking  grimaces.  One  week  the  tongue  may  be 
chiefly  concerned,  next  week  the  lips  or  eyebrows. 

The  movements  are  automatic  and  involuntary. 
By  extreme  effort  of  will  they  may  be  suppressed  for  a 
little  while,  but  are  sure  to  reappear  as  soon  as  effort 
is  relaxed;  or  if  the  tic  is  conquered  in  one  location,  it 
reappears  elsewhere.  To  punish,  nag,  or  scold  children 
for  their  habit-spasms  is  sheer  cruelty.  As  well  combat 
stuttering  with  the  rod.  The  defect  is  always  aggra- 
vated by  unsympathetic  treatment.  Rewards  and 
praise  for  successful  control  are  much  more  efficacious. 
Daily  practice  in  self-control  before  a  mirror,  motor 
exercises  involving  arms,  neck,  muscles  of  respiration, 
etc.,  have  been  used  to  advantage. 

But  tics,  habit-spasms,  etc.,  are  now  believed  to 
be  usually  of  psychical  origin.  Anaemia,  over-pressure, 
and  reflex  irritations,  such  as  intestinal  parasites,  de- 
fective teeth,  a  sore  on  the  face,  etc.,  may  be  the  occa- 
sion of  their  appearance,  but  are  seldom,  if  ever,  the 
true  cause.  They  are  more  often  associated  with  emo- 
tional repression,  obsessions,  phobias,  and  other  evi- 
dences of  functional  instability,  and,  as  Williams  has 
shown,  are  usually  curable  by  suggestion  and  the 
methods  of  psycho-analysis.  Sometimes  they  disappear 
of  themselves,  especially  if  the  child  is  not  punished  or 
scolded.  In  other  cases,  if  not  properly  treated,  they 
become  fixed  by  habit  almost  beyond  eradication. 
Strong  emotion,  worry,  and  overwork  aggravate  them. 


PREVENTIVE  MENTAL  HYGIENE         815 

Here,  as  everywhere  else,  prevention  is  better  than 
cure,  and  much  easier.  Marked  and  intractable  cases 
should  be  taken  from  school  because  of  the  danger  of 
psychical  contagion. 

Nervous  automatisms  differ  from  tics  and  habit- 
spasms  in  being  less  spasmodic  and  less  confined  to 
particular  muscles.  All  sorts  of  aimless  movements  are 
included  here,  such  as  shuffling  the  feet,  fingering  pencil, 
button,  the  hair,  etc.,  pulling  at  the  ear,  rubbing  the 
nose,  biting  the  lips  or  nails,  stretching  the  fingers, 
tapping,  turning,  thumping  the  knees,  and  the  like. 
To  a  greater  or  less  degree  automatisms  are  almost 
universal,  and  unless  excessive  need  not  occasion  con- 
cern. Lindley  (32)  found  that  the  "  accessory  "  muscles 
are  more  often  involved  than  the  "fundamental,"  par- 
ticularly in  the  upper  grades;  that  there  is  little  differ- 
ence between  the  sexes;  that  they  are  greatly  increased 
by  intense  mental  effort;  and  that  they  are  especially 
characteristic  of  fatigue  states.  Automatisms  indicate 
defective  control  rather  than  excess  of  energy,  and  are 
aggravated  by  the  school's  repression  of  "fundamental " 
movements.  The  important  point  for  the  teacher  to 
understand  is  that  the  nervous  restlessness  of  the  child 
who  never  sits  still  is  not  due  to  willfulness.  It  is  better 
to  send  such  a  child  out  to  play,  or  to  think  up  some 
errand  for  him  to  do,  than  to  nag  or  punish.  If  the 
restlessness  is  chronic  and  extreme,  thorough  medical 
examination  should  be  secured. 


316    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

Epileptic  school  children 

True  epilepsy  is  probably  always  due  to  some 
hereditary  defect  of  the  central  nervous  system,  and 
is  seldom  curable.  Usually,  though  not  always,  it 
involves  progressive  mental  deterioration  leading  to  a 
marked  degree  of  feeble-mindedness.  Tests  of  several 
hundred  epileptic  children  at  the  New  Jersey  Epilep- 
tic Village  at  Skillman  (56)  showed  an  average  mental 
retardation  of  three  to  four  years  at  the  age  of  10  or 
11,  increasing  to  seven  or  eight  years  by  the  age  of  15. 
Such  cases  really  belong  in  separate  schools  or  insti- 
tutions where  they  can  have  the  medical  supervision 
and  the  special  educational  treatment  suited  to  their 
needs.  If  the  fits  are  of  such  a  character,  or  if  they 
occur  at  such  times,  as  to  disturb  the  work  of  the 
school,  the  epileptic  child  should  under  no  circum- 
stances be  permitted  to  attend  classes  with  normal 
children. 

Some  cases  of  what  appears  to  be  epilepsy  are  due 
to  bodily  disturbances,  such  as  auto-intoxications,  eye- 
strain,  decayed  teeth,  intestinal  parasites,  nasal 
growths,  etc. 

There  is  a  mental  equivalent  of  epilepsy,  so-called 
"psychic  epilepsy,"  the  nature  of  which  all  teachers 
should  be  acquainted  with.  Psychic  epilepsy  is  a  kind 
of  mental  explosion,  "brain-storm,"  during  which  the 
patient  may  make  an  attack  or  do  and  say  all  sorts  of 
unaccustomed  things.  The  period  may  last  from  a  few 
minutes  to  several  hours,  and  is  followed  by  a  normal 
state  in  which  the  patient  remembers  little  or  nothing 


PREVENTIVE  MENTAL  HYGIENE         317 

of  his  unusual  acts.  Swift  (51)  cites  the  case  of  a  school 
girl  eight  years  old  who,  "while  standing  in  line  with 
her  classmates,  suddenly  broke  away  from  the  others 
and  ran  around  in  a  circle  three  or  four  times,  then 
looked  confused,  giggled  a  little,  and  became  quiet. 
When  reprimanded  by  the  teacher  she  insisted  that  she 
did  not  know  what  had  happened."  In  this  case  the 
attacks  became  frequent  and  were  succeeded  by  true 
epileptic  seizures. 

Dr.  Healy,  who  has  for  several  years  been  engaged 
in  a  psychological  and  medical  study  of  juvenile  of- 
fenders in  the  Psychopathic  Institute  connected  with 
the  juvenile  courts  of  Chicago,  found  that  more  than 
7  per  cent  of  700  third-time  offenders  were  victims  of 
psychic  epilepsy.  Sometime,  perhaps,  we  shall  know 
enough  to  substitute  medical  care  and  education  in 
place  of  the  punishment  usually  meted  out  to  such 
unfortunates.  Likewise  the  teacher  would  do  well  to 
take  a  sympathetic  attitude  toward  the  school  child, 
by  no  means  rare,  who  is  subject  to  sudden  explosions 
of  anger  or  irritability.  The  following  instance  came 
under  the  observation  of  the  writer :  — 

Boy  of  14,  mentally  retarded  (in  the  third  grade),  usually 
good-natured  and  quite  inoffensive,  became  enraged  one  day 
at  school  over  some  trifling  incident  and  struck  one  of  the 
older  girls  senseless.  The  teacher,  a  man,  considered  the  act 
as  purely  volitional,  and  beat  the  boy  unmercifully. 


CHAPTER  XVIII 

PREVENTIVE  MENTAL  HYGIENE 
HI.    THE   EDUCATION   OF   NERVOUS  CHILDREN 

MOST  authorities  on  mental  diseases  believe  that  the 
appearance  of  any  severe  neurosis  (other  than  a  certain 
few  due  to  infectious  diseases  or  toxins  causing  definite 
anatomical  lesions)  always  denotes  an  inherent  psy- 
chopathic tendency  in  the  subject.  Even  granting 
this,  however,  we  are  not  forced  to  take  the  fatalistic 
point  of  view.  The  unfavorable  heredity  is,  after  all, 
only  the  inheritance  of  a  tendency.  Whether  the  evil 
made  possible  by  heredity  materializes  probably  de- 
pends in  a  majority  of  cases  upon  what  we  may  call 
accidental  factors  of  environment. 

The  accidental  factors  may  be  divided  into  two 
groups:  (1)  Preventable  physical  abnormalities  which 
favor  the  development  of  nervous  conditions.  Among 
these  are  adenoids,  eye-strain,  intestinal  wTorms,  mal- 
nutrition, impacted  or  decaying  teeth,  the  toxins  re- 
sulting from  overwork  or  the  incomplete  elimination 
of  body  wastes,  lack  of  exercise,  fresh  air,  sleep,  etc. 
(2)  Faulty  education,  particularly  of  the  emotional 
and  volitional  functions. 

The  necessity  of  attending  to  the  factors  named  in 
the  first  group  is  admitted  in  all  schemes  of  psychopro- 
phylaxis,  while  the  importance  of  the  pedagogical 
factor  is  almost  as  universally  neglected. 


PREVENTIVE  MENTAL  HYGIENE         319 

Faulty  education  as  related  to  nervous  disorders 

Nevertheless,  modern  researches  in  functional  psy- 
chopathology  are  constantly  making  it  evident  that 
the  misery  suffered  by  neurotics  is  due  very  largely 
to  faulty  education,  using  this  term  in  the  broadest 
sense.  "Alas,"  said  Goethe,  in  Wiihelm  Meister,  "how 
much  there  is  in  education,  in  our  social  institutions, 
to  prepare  us  and  our  children  for  insanity." 

In  our  classification  of  people  as  nervous,  weak, 
balanced,  self-confident,  selfish,  magnanimous,  etc., 
we  tend  to  lose  sight  of  the  conditions  and  experiences 
which  have  made  them  so.  Most  of  us  look  upon  im- 
perfections as  intentional  products  of  a  perverted  will, 
forgetting  that  the  will  itself,  even  character,  is  but 
the  composite  resultant  of  an  infinite  number  of  in- 
dividual acts  and  experiences.  Nothing  happens  in 
mental  cosmogony,  not  even  the  perverted  will.  What 
we  are  going  to  think  or  do,  how  we  are  going  to  feel, 
depends  upon  what  we  have  thought,  done,  and  felt. 
Character  is  "an  epitome  of  the  past  and  a  forecast 
of  the  future"  (46).  The  only  reason  things  seem  to 
happen  in  mentation  is  that  many  of  the  connecting 
links  are  hidden  below  the  threshold  of  consciousness. 
The  study  of  the  subconscious,  however,  has  at  last 
succeeded  in  bringing  to  light  submerged,  associative 
elements  which  explain  many  of  these  apparent  happen- 
ings. Law  and  order  are  thus  taking  the  place  of  what 
before  was  psychological  chaos. 


320    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

Suppressed  feelings 

In  the  most  literal  sense,  everything  that  is  experi- 
enced is  conserved.  Not  that  it  can  be  recalled,  any 
moment,  by  an  act  of  the  will;  but  conserved  in  the 
sense  that  it  will  remain  functionally  active  as  a  deter- 
miner of  future  mentation.  Thus  Freud  demonstrates 
that  when  in  childhood  a  disagreeable  emotion  is  sup- 
pressed, carrying  with  it  into  apparent  oblivion  a  host 
of  associated  memories,  the  disagreeable  emotion  and 
its  suppressed  associates  are  by  no  means  annihilated, 
but  may  reappear  in  adult  life  as  phobias,  obsessions, 
hysteria,  etc.,  whose  origin  is  not  suspected  by  the 
patient  and  can  only  be  brought  to  light  by  the  methods 
of  psycho-analysis.1 

Nervous  states,  therefore,  if  we  can  accept  the  func- 
tional explanation  of  the  Freudians,  may  have  as  their 
basis  unassimilable  experiences,  experiences  which 
because  of  their  painful  feeling  tone  have  been  sup- 
pressed as  by  a  mental  censorship. 

But  suppression,  as  already  indicated,  is  not  equiva- 
lent to  annihilation.  The  suppressed  elements  remain 
as  "disturbers  of  the  peace,"  giving  rise  to  inner  men- 
tal conflicts,  to  anxieties,  stuttering,  obsessions,  hysteri- 
cal symptoms,  and  the  like.  During  sleep,  when  the 
faculty  of  censorship  is  weakest,  they  obtrude  them- 
gelves  in  the  form  of  night  terrors,  dreams  involving 

1  For  an  exposition  and  criticism  of  psycho-analysis  see  the 
article  by  Harry  W.  Chase,  "  Psycho- Analysis  and  the  Unconscious," 
Pedagogical  Seminary,  vol.  xvn,  pp.  281-327.  Also  other  references 
at  the  close  of  this  chapter,  especially  reference  3. 


PREVENTIVE  MENTAL  HYGIENE         321 

wish  fulfillment,  etc.  Even  in  waking  life  they  may 
exert  a  constant  pull  sufficiently  strong  to  determine 
the  direction  which  life  activities  shall  take.  It  is  a 
wise  man  who  knows  the  real  sources  of  his  likes,  his 
aversions,  his  ideals,  and  his  prejudices. 

The  puritanical  suppression  of  the  play  instinct  and 
of  the  spirit  of  adventure  in  the  young  may  rid  us  of 
certain  troublesome  pranks  and  inconveniences,  but 
we  are  coming  to  believe  that  it  creates  a  harvest  of 
vice,  crime,  and  neuroses.  Whatever  else  play  may 
mean,  Aristotle's  conception  of  it  as  a  catharsis  is 
essentially  correct.  The  child  whose  conduct  is  molded 
too  closely  by  adult  moral  standards,  whose  devilish 
spirit  of  adventure  is  denied  all  the  customary  outlets, 
is  likely  some  day  to  overflow  with  the  accumulated 
"cussedness"  of  years.  Mental  hygiene  demands  that 
the  larks  and  pranks  of  boyhood  be  not  too  severely 
frowned  upon. 

Prevention  of  morbid  fears 

There  is  danger  in  all  forms  of  mental  irreconcilia- 
tions  which  lead  to  suppression.  The  condition  result- 
ing is  one  of  imperfect  mental  unity,  or  in  extreme  cases 
even  double  personality.  Conflicts  arise,  entailing 
fears,  the  feeling  of  inadequacy,  etc.  An  important 
function  of  education,  as  Plato  observed,  is  to  teach 
children  to  fear  aright,  which  means  to  free  them  from 
the  fears  that  are  unreasonable,  imaginary,  or  the  out- 
growth of  weakness.  Fear  is  the  evil  genius  of  most 
nervous  people.  The  fear  of  insomnia  keeps  them 


322    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

awake;  the  fear  of  exhaustion  induces  in  them  the 
chronic  feeling  of  fatigue;  the  fear  of  not  succeeding 
makes  hopeless  failures  of  them;  the  fear  of  their  own 
impulses  makes  them  slaves  of  each  momentary  whim. 
Over-conscientiousness,  which  comes  as  a  rule  from 
self -distrust,  does  not  betoken  moral  strength,  but  self- 
distrust,  and  is  a  poor  guaranty  of  right  conduct. 
"Keyed-up  prepossessedness,"  sometimes  seen  in  one 
who  sets  about  doing  something  with  all  his  might, 
has  in  it  an  element  of  fear  and  has  been  experimentally 
proved  to  be  unfavorable  to  success.1  The  school 
should  assist  parents  to  "discover  and  to  remove  the 
overgrowths  of  fear"  which  attach  themselves  para- 
sitically  to  the  lives  of  so  many  children,  and  to  pre- 
vent the  development  of  irrational  fears,  prejudices, 
and  aversions. 

There  is  danger,  however,  that  the  extreme  applica- 
tions made  of  this  principle  by  Christian  Scientists  will 
blind  us  to  its  essential  truth.  The  best  way  to  com- 
bat fear  is  by  reason  and  by  the  gradual  habituation 
to  courageous  acts.  Once  convince  a  man  that  two 
hours  of  sleep,  more  or  less,  will  not  matter  much,  he 
will  cease  to  fear  insomnia  and  will  sleep.  If  the  child 
fears  the  dark,  let  him  become  accustomed,  little  by 
little,  to  venturing  alone  in  the  dark,  and  each  suc- 
cessful venture  will  add  to  his  courage:  only  it  is  nec- 
essary to  go  slowly  to  avoid  shock.  Once  thoroughly 
convince  the  stutterer,  by  speech  drills  or  otherwise, 

1  See  W.  F.  Book:  The  Psychology  of  Skill,  uiih  Special  Reference 
to  Typewriting.  1908,  pp.  136  /. 


PREVENTIVE  MENTAL  HYGIENE         323 

that  it  is  possible  for  him  to  speak  without  tripping, 
and  he  is  placed  well  on  the  way  to  recovery.  By  a 
little  experience  of  success,  appropriately  arranged  for 
by  a  thoughtful  teacher  or  parent,  the  child  who  is 
diffident  and  distrustful  of  his  powers  is  released  from 
his  paralysis  of  will  and  inspired  with  confidence. 

Even  when  the  difficulties  which  beset  the  fearful 
and  timid  are  not  wholly  imaginary,  the  patients  can 
be  taught  to  face  them  honestly  and  to  make  the  best 
of  a  bad  situation.  The  neurasthenic  has  been  fitly 
described  as  "  the  person  who  runs  away  from  a  diffi- 
culty into  the  refuge  of  a  nervous  breakdown."  It  is 
especially  destructive  of  mental  integrity  for  the  child 
to  be  always  shielded  from  the  consequences  of  his  own 
acts;  whence  the  sanifying  influence  of  plays  and  games 
in  which  error  brings  its  certain  penalty  and  skill  its 
quick  reward.  By  a  scheme  of  treatment  thoroughly 
enough  reversed  from  its  true  order  the  bravest  child 
may  be  made  into  a  coward.  Conversely,  the  most 
timid  may  be  made  to  tingle  with  confidence  and 
courage. 

The  value  of  social  experience 

Social  experience  is  an  indispensable  corrective  for 
the  introspective  tendencies  of  nervous  children. 
Because  of  self-distrust,  morbid  suspicion,  egotism,  or 
"queerness,"  they  adjust  imperfectly  to  social  environ- 
ment, and  are  likely  to  withdraw  into  themselves,  to 
contemplate  life  rather  than  to  live  it.  In  this  way  the 
abnormality  is  aggravated.  The  social  outcast,  whether 
he  be  one  from  choice  or  otherwise,  usually  lacks  the 


324    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

finer  elements  of  mental  balance.  The  best  corrective 
of  character  development  is  to  have  to  face  the  natural 
social  reactions  which  our  conduct  calls  forth  from 
others.  "  Es  formet  ein  Talent  sich  in  der  Stille;  sich 
em  Karakter  in  dem  Strom  der  Welt."1 

Methods  of  discipline 

The  hygiene  of  discipline  plays  no  small  part  in 
psycho-prophylaxis.  Nagging,  arbitrary,  or  tyrannical 
parents  and  teachers  either  destroy  the  child's  will  or 
make  it  rebellious.  The  unstable  and  whimsical  child 
is  often  but  the  victim  of  a  nervous  mother.  The 
tyrannical,  domineering  father  need  not  wonder  when 
his  son  develops  into  a  psychasthenic,  weak,  vacillating, 
and  dependent  upon  others  for  guidance. 

Training  in  self-reliance  and  self-control 

Parental  over-solicitude  and  excessive  affection 
likewise  tend  to  make  the  child  dependent  and  to  de- 
velop a  mania  for  sympathy,  the  besoin  d'etre  aime* 
The  love  bonds  of  infancy  should  normally  dissolve  as 
the  child  reaches  maturity  and  be  replaced  by  a  tie 
of  somewhat  different  nature.  When  this  does  not 
occur,  when  the  relation  of  child  to  parent  retains  its 
infantile  quality,  the  foundation  is  laid  for  a  life  of 
weakness  and  nervous  invalidism.  How  to  free  the 
child  from  the  circle  of  parental  influence,  without  en- 
dangering the  mellower  filial  attachment  which  should 

1  Talent  is  nourished  in  solitude ;  character,  by  a  life  of  action. 
*  Abnormal  craving  for  love. 


PREVENTIVE  MENTAL  HYGIENE         325 

succeed  it,  is  one  of  the  important  problems  of  child- 
training. 

Self-reliance  does  not  grow  up  out  of  habits  of  de- 
pendence, nor  does  steadfastness  develop  out  of  unin- 
hibited impulses.  If  we  would  free  children  from  bond- 
age to  their  whims,  we  must  tram  them  to  concentrate, 
to  attend.  The  power  of  concentration  is  not  a  faculty, 
but  rather  the  whole  volitional  attitude  toward  one's 
work,  a  function  which  enters  into  all  of  one's  intel- 
lectual activities.  It  cannot  be  profitably  trained  by 
set  exercises.  What  one  has  of  it  represents  the  total 
effect  of  the  countless  individual  strokes  of  attention 
which  one  habitually  gives.  If  these  are  allowed  to 
be  brief,  aimless,  or  ineffectual,  the  injury  so  wrought 
cannot  be  corrected  by  a  few  formal  exercises.  Short- 
cut processes  and  pedagogical  dosage  can  no  more  take 
the  place  of  real  education  than  patent  medicines  can 
replace  the  hygiene  of  physical  development.  In  its 
play  and  in  its  work  the  child  should,  therefore,  be 
encouraged  to  concentrate  instead  of  being  interrupted 
and  dragged  from  one  exercise  to  another. 

The  extreme  suggestibility  which  marks  the  hysteria 
psychosis  is  best  combated  by  a  training  which  fosters, 
without  overworking,  the  power  of  inhibition.  As 
Williams  well  says,  let  the  child  "be  taught  not  to 
strike,  not  to  follow,  not  to  jeer,  not  to  give  in,  even 
though  others  do  so."  Let  him  "learn  to  take  pride  in 
being  his  own  man,  and  not  a  puppet  in  the  hands  of 
others"  (61).  The  culture  of  rationality  also  helps,  for 
the  hysterical  is  first  and  last  uncritical.  Whims  and 


326    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

shallow  impulsiveness  do  not  thrive  in  the  light  of 
reason.  Hysteria  will  be  less  common  when  education, 
from  the  kindergarten  to  the  university,  has  more  of 
the  scientific  background.  Irrational  prejudices  can 
be  combated  by  the  same  means. 

Cultivating  efficiency 

Since  habits  are  so  much  more  persistent  than  is 
usually  believed,  there  is  special  danger  in  the  slump, 
intellectual  or  moral.  The  habits  of  peevish  selfishness 
and  fretfulness  which  are  favored  by  a  temporary  ill- 
ness, with  its  bodily  weakness,  sympathetic  nursing, 
and  friendly  solicitude,  sometimes  remain  and  poison 
all  the  rest  of  life.  When  children  are  not  kept  to  their 
best  level  of  scholarship  they  suffer  an  intellectual 
slump.  Herein  lies  the  great  danger  of  making  school 
work  too  easy.  By  holding  every  child  to  the  lock-step 
of  regular  school  performance,  genius  is  effectually 
starved.  The  child  with  real  ability  is  enslaved  by 
"habits  of  inferiority"  to  his  own  best  self.  By  dint  of 
repeating  things  which  are  already  known,  or  by  being 
kept  over-long  at  what  is  easily  acquired,  the  mind 
becomes  prematurely  arrested.  Curiosity  is  deadened 
and  all  the  higher  intellectual  processes  stunted.  Har- 
ris, James,  and  Sidis  have  dwelt  with  emphasis  on  this 
important  principle  of  education. 

Perhaps  all  of  us  have  reserves  of  energy  which  we 
habitually  fail  to  use  and  rich  intellectual  possibilities 
which  we  have  failed  to  realize.  The  gates  to  these 
treasures  are  closed  and  sealed  by  the  low  opinion  we 


PREVENTIVE  MENTAL  HYGIENE         327 

entertain  of  ourselves,  by  the  discouragement  and  self- 
distrust  incident  to  failure,  and  by  other  inhibitions  or 
repressions.  As  a  means  of  tapping  the  hidden  treas- 
ures of  power,  James  instances  the  dynamogenic  effect 
of  ideals,  religion,  patriotism,  critical  experiences,  etc.; 
Sidis,  the  loosening  of  the  inhibitory  stresses  by  sug- 
gestion, by  hypnoidization,  or  by  otherwise  convinc- 
ing the  subject  of  the  reality  of  his  unused  powers. 
What  the  psychasthenic  lacks  mainly  is  the  conviction 
of  strength,  not  strength  itself. 

Failure  and  success  may  indicate  ability  or  they 
maybe  the  mere  products  of  habit.  That  a  majority  of 
children  fail  of  promotion  once  or  oftener  during  their 
school  life  is  one  of  the  sad  facts  in  our  present  scheme 
of  education.  Still  more  deplorable  and  costly,  how- 
ever, is  the  failure  of  the  talented  few  to  go  through 
school  at  the  high  level  of  intellectual  performance 
possible  to  them. 

The  sanifying  effects  of  work 

The  healthful  influence  of  work  has  already  been 
mentioned.  The  "instinct  of  workmanship"  is  one  of 
the  most  generic  of  human  motives,  and  when  given 
a  suitable  outlet  is  one  of  the  most  sanifying.  Espe- 
cially to  be  emphasized  is  the  wholesome  effect  of 
objective  interests  and  employments  as  an  antidote 
to  morbid  self -analysis  and  one-sided  imagination. 

Vocational  guidance  thus  becomes  an  indispensable 
agent  in  preventive  mental  hygiene.  There  is  no  hope 
for  the  neurotic  individual  who  is  not  successfully 


328    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

engaged  in  useful  arid  interesting  work.  Hysteria  is 
preeminently  a  disease  of  the  unemployed,  or  the  aim- 
lessly employed.  Work  which  is  interesting  and  fruit- 
ful so  engages  and  practices  the  synthesizing  powers 
of  will,  so  unifies  the  personality,  that  disagreeable 
and  submerged  experiences  have  no  chance  to  produce 
their  effects  of  mental  disintegration.  The  moral  as 
well  as  the  industrial  efficiency  of  the  world  would  be 
easily  doubled  if  each  individual  were  doing  the  work 
for  which  he  is  best  adapted. 

Danger  of  shock 

It  is  a  matter  of  common  observation  that  neurotic 
disturbances  are  frequently  ushered  in  by  a  shock, 
such  as  accident,  sudden  grief,  fright,  disappointment, 
etc.  A  woman  may  become  insane  after  the  death  of 
her  child,  the  school  girl  may  develop  chorea  or  stut- 
tering immediately  after  a  fright.  In  such  cases  the 
grief  or  fright  should  not  be  regarded  as  the  sole  cause, 
but  rather  as  the  occasion  for  bringing  forth  what  is 
already  latent  and  near  the  surface.  Shocks  of  grief, 
pain,  fright,  etc.,  do  not  start  neuroses  with  every  one. 
Nevertheless  strong  emotions  suddenly  induced  are 
likely  to  produce  injury  and  should  as  far  as  possible  be 
avoided.  The  child's  life  should  be  one  of  fairly  even 
tenor,  at  least  until  character  and  personality  have  had 
time  to  set. 

Many  other  principles  of  preventive  mental  hygiene 
could  be  listed  and  illustrated,  but  perhaps  enougli  has 


PREVENTIVE  MENTAL  HYGIENE         329 

been  said  to  show  that,  in  the  main,  the  principles 
involved  are  those  of  right  education  generally.  The 
same  may  be  said  for  the  methods  of  psychotherapy,  or 
mental  cure,  which  are  coming  to  rely  more  and  more 
upon  the  method  of  reeducation.  By  following  the 
strands  of  a  neurosis  back  to  its  starting-point,  back 
to  the  shock,  or  fear,  or  mental  conflict  which  gave  it 
birth,  the  fault  in  mental  development  may  be  cor- 
rected. The  fears  may  be  rationalized,  the  conflicts 
aired,  so  to  speak,  and  brought  to  an  understanding. 
Timidity  may  be  educated  out  and  replaced  by  confi- 
dence, hope,  and  the  habit  of  success.  But  the  process 
of  reeducation  is  slow  and  its  issue  sometimes  doubtful 
even  when  guided  by  the  competent  psycho-patholo- 
gist. Moreover,  the  latter  is  rarely  available;  there 
are  not  more  than  a  few  dozen  hi  the  entire  country.  It 
is  easier  and  more  effective  to  manage  the  work  of 
education  in  such  a  way  that  reeducation  will  become 
less  frequently  necessary.  All  of  the  school's  activities 
will  ultimately  be  judged  by  the  contribution  they 
make  to  preventive  mental  hygiene  hi  the  broad  sense. 

Children's  sorrows 

To  many  people  the  sorrows  of  children  are  but  fool- 
ish tears;  their  deepest  griefs,  humiliations,  and  disap- 
pointments seem  but  transitory  affairs.  Nothing  could 
be  further  from  the  truth.  Children's  emotions  are 
more  compelling  than  our  own;  their  sorrows  are  the 
most  real  there  are.  The  child  lives  in  the  present,  and 
his  griefs,  unlike  those  of  men  and  women,  are  little 


330    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

mitigated  by  the  memory  of  former  joys  or  by  the 
hope  of  others  yet  to  come. 

All  of  this  and  much  more  relating  to  the  tragedies 
of  childhood  is  painfully  depicted  in  the  recent  litera- 
ture on  children's  suicides.  These  seem  to  be  on  the 
increase  in  most  civilized  countries,  and  to  show  a 
tendency  to  occur  lower  and  lower  in  the  age  scale. 
If  the  figures  for  France  and  Germany  hold  for  the 
United  States,  it  is  probable  that  the  annual  number 
of  suicides  of  children  under  17  years  of  age  amounts  to 
about  500,  and  that  the  total  number  under  21  yeara 
exceeds  2000. 

Eulenberg's  analysis  of  1117  cases  in  Germany  indi- 
cates that  over  one  third  of  all  were  caused  wholly  or 
in  part  by  the  school.  The  causes  most  often  named 
in  this  connection  are  fear  of  punishment,  failure  of 
promotion,  unjust  treatment,  mental  overwork,  etc. 
Even  when  the  school  is  not  the  fundamental  cause  of 
the  school  child's  suicide,  it  is  often  blamable  for  failure 
to  recognize  the  morbid  mental  condition  and  to  sur- 
round the  child  with  the  appropriate  counteracting 
influences.1 

Special  schools  for  nervous  children 

In  closing  this  chapter  mention  should  be  made  of 
the  rural  school  homes  (Landerziehungsheim),  which  are 
becoming  popular  in  Germany  for  nervous  or  other- 
wise troublesome  children.2  Such  schools  have  their 

1  For  a  discussion  of  this  entire  subject  see  reference  53,  where  the 
author  has  set  forth  the  statistics  and  summarized  the  causes. 

2  See,  especially,  references  33  and  54  at  the  close  of  this  chapter. 


PREVENTIVE  MENTAL  HYGIENE         331 

gardens  and  fields  to  cultivate,  parks,  swimming-pools, 
athletic  fields,  and  endless  opportunity  for  outdoor 
living,  country  tramps,  etc.  They  are  usually  con- 
ducted on  the  cottage  plan,  and  are  provided  with 
medical  and  dental  supervision  and  treatment.  The 
study  program  is  somewhat  shorter  than  that  of  the 
usual  public  school,  sports  and  manual  occupations 
have  larger  scope,  and  discipline  is  more  natural,  and 
confined  principally  to  inculcation  of  the  essentials 
of  right  conduct.  The  social  spirit  of  cooperation  and 
mutual  helpfulness  is  fostered.  The  instructors  are 
comrades  and  leaders  rather  than  teachers  in  the  ordi- 
nary sense. 

The  rural  school  home  is  especially  desirable  for 
the  child  whose  home  environment  is  faulty  and  for 
children  of  neuropathic  tendency.  Besides  providing 
the  ideal  hygienic  environment,  it  has  a  special  ad- 
vantage in  the  fact  that  it  can  order  the  entire  life  of 
the  child  as  long  as  he  is  in  attendance.  Too  often 
the  good  that  is  daily  wrought  by  the  ordinary  day 
school  is  undone  before  the  following  day  by  the  evils 
of  home  life  or  by  uncontrolled  street  associations. 
Although  we  cannot  hope  to  have  enough  rural  school 
homes  for  more  than  a  few  of  the  children  who  would 
profit  from  the  treatment,  they  stand  in  many  respects 
as  an  admirable  model  pointing  the  way  to  needed  and 
possible  reforms  in  the  conduct  of  education  every- 
where. 


332    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


SELECTED  REFERENCES 

(Only  those  references  having  immediate  bearing  upon  preventive 
mental  hygiene  in  relation  to  education  are  included  in  this  list. 
See  also  references  to  chapters  xrx  to  xxi.) 

1.  Gilbert  Ballet:  Neurasthenia.   1908,  pp.  407. 

2.  Bayerthal:  "The  Work  of  the  School  Doctor  and  Prophylactic 
Measures  in  Case  of  Nervous  and  Mental  Disease."  Inter.  Mag. 
Sch.  Hyg.,  1912,  pp.  513-16. 

3.  A.  A.  Brill:  Psychoanalysis:  Its  Theories  and  Practical  Applica- 
tion.  1912,  pp.  337. 

4.  W.  H.  Burnham:  "European  Investigations  in  School  Hygi- 
ene."  Ped.  Sem.,  1910,  pp.  525-33. 

*5.  T.  Clouston:  The  Hygiene  of  Mind.   1909,  pp.  284. 
6.  T.  Clouston:  Neuroses  of  Development.  1891,  pp.  188.   (Chiefly 
of  historical  value.) 

*7.  Dannemann,  Schober  u.  Schulze:  Encyklopadisches  Handbuch 
der  Heilpadagogik.  Halle,  1911,  pp.  1974.  (Inclusive  and  au- 
thoritative.) 

8.  Dirks:  "Der  Tic  im  Kindersalter  u.  seine  erziehliche  Behand- 
lung."  Zt.  f.  Kinderforsch.,  vol.  xin,  pp.  257-67,  and  290- 
97. 

*9.  John  E.  Donley:  "  Psvchotherapy  and  Reeducation."  Jour. 
Abn.  Psych.,  1911,  pp.  1-10. 

10.  Paul    Dubois:    "Conception  psychologique  de  1'origine  des 
psychopathies."  Arch,  de  Psych.,  vol.  x,  1910-11,  pp.  47-70. 

11.  Georg.  Flatau:  "Zur  Psychologic  der  nervosen  Kinder."  Zt.f. 
Pad.  Psych.,  1907,  pp.  445-57. 

*12.  A.  Forel:  Nervous  and  Mental  Hygiene.   1907,  pp.  343. 
13.  S.  I.  Franz:  "Hysteria."  In  Monroe's  Encyclopedia  of  Educa- 
tion, 1912,  vol.  in,  p.  365. 

*14.  S.  Freud:  Selected  Papers  on  Hysteria  and  Other  Neuroses. 
Translated  by  Brill.  No.  4  of  Nerv.  and  Men.  Dis.  Monog.  Series. 

15.  S.  Freud:  The  Interpretation  of  Dreams.  Translated  by  BrilL 
1913,  pp.  500. 

16.  W.  L.  Gard:  "Some  Neurological  and  Psychological  Aspects  of 
Shock."   Ped.  Sem.,  1908. 

*17.  Leonard  B.  Guthrie:  Functional  Nervous  Disorders  of  Childhood. 

1909,  pp.  300. 
18.  W.  T.  Harris:  "A  Study  of  Arrested  Development  in  Children 

as  produced  by  Injudicious  School  Methods."  Education,  vol. 

xx,  pp.  453-66. 
*19.  Th.  Heller:  Grundniss  der  Heilpadagogik.   1904,  pp.  366.   (See 

especially  pp.  272-331.) 
*20.  Dr.  W.  Hellpach:  "Die  Hysterie  u.  d.  moderne  Schule." 

Inter.  May.  Sch.  Hyg.,  1905,  pp.  222-52. 

21.  Leo  Hirschlaff:  "Zur  Gesundheitspflege  des  Nervensystems." 
Zt.f.  Pad.  Psych.,  1903,  pp.  298-322. 

22.  August  Hoch:  "Some  of  the  Mental  Mechanisms  in  Dementia 


PREVENTIVE  MENTAL  HYGIENE         333 

Prsecox."   Jour.  Abn.  Psych.,  December,  1910,  and  January, 
1911. 
23.  L.  E.  Holt:  Diseases  of  Infancy  and  Childhood.    19158.    (See 

contents;  especially  "Chorea.") 
*24.  P.  Janet:  Les  nevroses.    1910,  pp.  397. 

25.  P.Janet:  The  Major  Symptoms  of  Hysteria.   1908. 
*26.  S.  E.  Jelliffe:  "Signs  of  Pre-dementia  Prsecox;  their  Signifi- 
cance and  Pedagogical  Prophylaxis."    Am.  Jour.  Med.  Sci., 

1907,  157-82. 

*27.  Ernest  Jones:   "Psychoanalysis  and  Education."    Jour.  Ed. 
Psych.,  1910,  pp.  497-520,  and  1912,  pp.  241-56. 

28.  Ernest  Jones:   "The  Psychopathology  of  Everyday  Life." 
Am.  Jour.  Psych.,  1911,  pp.  477-527. 

29.  C.  Jung:   "Psychology  of  Dementia  Praecox."  Translated  by 
Brill.  Jour,  of  Nerv.  and  Men.  Dis.  Monog.  Series,  1909. 

30.  Aug.  Lemaitre:  La  vie  mentale  de  V adolescent  et  ses  anomalies. 

1910,  pp.  240. 

31.  D.  F.  Lincoln:  Sanity  of  Mind.  1901,  pp.  177.   (See  contents.) 

82.  E.  H.  Lindley:  "A  Preliminary  Study  of  Some  of  the  Motor 
Phenomena  of  Mental  Effort."    Am.  Jour.  Psych.,  vol.  vn, 
1895-96,  pp.  491-517. 

83.  Bruno  Maennel:  "Ein  Erziehungsheim  f.  nervb'se  Kinder." 
Inter.  Mag.  Sch.  Hyg.,  1910,  pp.  324-29. 

84.  Mathieu:  "  Neurasthenic  et  dyspepsie  chez  les  jeunes  gens." 
Inter.  Mag.  Sch.  Hyg.,  1905,  pp.  252-59. 

85.  Henry  Maudsley:  Pathology  of  Mind.  1880.  (See  especially  pp. 
82-225.) 

86.  Meige  u.  Feindel:  Les  tics  et  leur  traitement.  Paris,  1902. 
*37.  Adolf  Meyer:   "The  Dynamic  Interpretation  of  Dementia 

Praecox."  Am.  Jour.  Psych.,  1910,  pp.  385-403. 
38.  Adolf  Meyer:   "The  Nature  and  Conception  of  Dementia 

Prsecox."  Jour.  Abn.   Psych.,  December,  January,  1910-11, 

pp.  274-85. 
*39.  Adolf  Meyer:  "Analysis  of  the  Neurotic  Constitution."  Am. 

Jour.  Psych.,  1903,  pp.  354-67. 
*40.  Adolf  Meyer:  "What  do  Histories  of  Cases  of  Insanity  teach 

us  concerning  Preventive    Mental  Hygiene?"  Psych.  Clinic, 

1908,  pp.  89-101. 

41.  C.  Pascal:  La  demence  precoce.  Paris,  1911,  pp.  300.   (Empha- 
sizes educational  aspects.) 
*42.  O.  Pfister:  "  Psychoanalysis  and  Child  Study."  School  Hygiene, 

1911,  pp.  366-74,  and  432-42. 

43.  Philippe  and  Boncour:  "Apropos  de  1'examen  medicopeda- 
gogique  des  ecoliers  epileptiques."  Inter.  Mag.  Sch.  Hyg.,  1905, 
pp.  259-70. 

44.  Carl  Polotzky:  "Nervose  Schiller."  Zt.f.  Schulges.,  1911,  pp. 
28-32. 

45.  Morton  Prince:  "The  Psychological  Principles  and  Field  of 
Psychotherapy."     In   Psycholherapeutics,    1910,   pp.    11-46. 
Boston,  R.  G.  Badger. 


334    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

*46.  James   P.   Putnam:   "Relation  of  Character  Formation  to 

Psychotherapy."    In   Psychotherapeutics,  1910,  pp.    185-204. 

Boston,  R.  G.  Badger. 
47.  Boris  Sidis:  "The  Psychotherapeutic  Value  of  the  Hypnoi- 

dal  State."   In  Psychotherapeutics,  1910,  pp.  119-44.    Boston, 

R.  G.  Badger. 
"*48.  G.  F.  Still:  Common  Disorders  and  Diseases  of  Childhood.  1910. 

(See  contents;  especially  "Chorea.") 

49.  Spitzner: "  Anzeichen  beginnender  Nervositat."  Zi.j.  Schulges., 
1903,  pp.  395  £. 

50.  W.  P.  Sprattling:  Epilepsy  and  its  Treatment.   1904. 
*51.  E.  J.  Swift:  Mind  in  the  Making.   1908,  pp.  116-69. 

52.  E.  W.  Taylor:  "Simple  Explanation  and  Reeducation  as  a 
Therapeutic  Method."  In  Psychotherapeutics,  1910,  pp.  25-85. 
Boston,  R.  G.  Badger. 

53.  Lewis  M.  Terman:  "The  Tragedies  of  Childhood"  (children's 
suicides).   The  Forum,  January,  1913,  pp.  41-4G. 

54.  J.  Triiper:  Das  Erziehungnheim  u.  Jungendsanatorium  auf  der 
Sophienhohe  bei  Jena.   pp.  84. 

55.  H.  Vogt:  Die  Epilepsie  im  KindesaHer.   Berlin,  1910,  pp.  225. 

56.  J.  E.  W.  Wallin:  Experimental  Studies  of  Mental  Dejectitei 
(epileptics).   1912,  pp.  154. 

57.  Francis  Warner:  The  Study  of  Children.    1898,  pp.  264.    (See 
especially  chapters  iv  to  vi.) 

*58.  Tom  Williams:  "  Psychoprophylaxis  in  Childhood."  Jour.  Abn. 
Psych.,  1909,  vol.  iv,  pp.  181-99.  Same  in  Psychotherapeutics, 
1910,  pp.  161-81.  Boston,  R.  G.  Badger. 

59.  Tom  Williams:  "The  Genesis  of  Hysterical  States  in  Childhood 
and  their  Relation  to  Fears  and  Obsessions."    Med.  Record, 
August  6,  1910. 

60.  Tom  Williams:  "Cases  of  Juvenile  Psychasthenia."  Am.  Jour. 
Med.  Sci.,  December,  1912,  pp.  865-74. 

*61.  Tom  Williams:  "Nervousness  and  Education."  Proc.  Cong. 
Am.  Sch.  Hyg.  Assoc.,  1910,  pp.  105-12. 

62.  Dr.  K.  Wendenburg:  "Ueber  Chorea  infectuosa   3.  Chorea 
hysterica."  Monatschrijtf.  psychiat.  u.  Neur.,  1910,  pp.  232-68. 

63.  H.   Zbinden:    "Conception   psychologique   du   nervosisme." 
Arch,  de  Psych.,  vol.  v,  1905-06,  pp.  185-244. 

64.  Th.  Ziehen:  Die  Erkennung  der  psychopathischen  Konstitution 
u.  d.  ojfentliche  Fiirsorge  f.   psychopathisch  teranlagte  Kinder. 
Berlin,  1912,  pp.  34. 


CHAPTER  XIX 

SPEECH  DEFECTS  AND  THE  HYGIENE  OF  THE  VOICE 

Stuttering  as  a  handicap 

THE  stuttering  child  presents  a  tragedy  to  which  a 
majority  of  teachers  and  parents  are  strangely  blind. 
At  home  the  onset  of  the  disease  is  a  signal  for  impa- 
tience and  reproof  on  the  part  of  the  parents.  They 
often  interrupt  the  child's  speech  with  scolding  or  with 
peremptory  orders  to  cease  stuttering.  School  entrance 
does  not  mend  the  situation,  but  is  itself  a  new  crisis. 
The  child  notes  with  humiliation  the  looks  and  smiles 
provoked  by  his  speech  efforts.  The  teacher  herself, 
if  not  exceptional,  is  prone  sooner  or  later  to  lose  pa- 
tience and  to  upbraid  the  unfortunate  in  the  pres- 
ence of  his  fellows.  She  may  accuse  him  of  carelessness, 
or  neglect  to  call  on  him  for  a  recitation,  and  may  even 
discuss  his  defect  with  other  children  in  his  presence. 
The  trouble  is,  of  course,  aggravated.  Every  speech 
sound  which  offers  the  slightest  difficulty  becomes  the 
focus  for  a  stubborn  phobia.  These  difficult  sounds 
are  more  and  more  slurred  over  in  fear.  The  very 
thought  of  having  to  attempt  them  may  throw  the 
whole  vocal  and  respiratory  mechanism  into  a  panic. 

Though  equal  to  other  children  in  intelligence,  the 

1  For  some  of  the  material  in  this  chapter  the  author  is  indebted 
to  Dr.  Hudson-Makuen,  of  Philadelphia,  and  Dr.  E.  W.  Scripture* 
of  New  York  City. 


836    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

stutterer,  as  Conradi's  statistics  prove  (4),  is  likely  to 
fail  in  classwork  and  to  become  retarded.  The  repe- 
tition of  stale  school  work  deadens  interest  with  dis- 
gust. The  child  receives  a  training  hi  failure.  On  the 
playground  he  encounters  jests,  badinage,  and  some- 
times ridicule.  In  the  shop  and  on  the  street  grown 
men  amuse  themselves  at  his  expense.  The  victim's 
whole  existence  is  poisoned.  The  more  sensitive  stut- 
terer comes  to  prefer  silence  to  ridicule.  He  retires  into 
himself,  and  as  a  result  often  becomes  ill-tempered, 
hypochondriac,  suspicious  of  others,  or  disagreeable. 
Lifelong  moral  suffering  and  permanent  defects  of 
character  may  be  the  issue.  If  the  speech  does  not 
become  normal,  the  vocational  outlook  is  altogether 
unpromising.  There  is  no  place  for  the  stutterer  in 
law,  medicine,  the  ministry,  teaching,  or  many  lines  of 
business.  Even  marriage,  on  terms  of  social  equality, 
is  made  difficult. 

The  incidence  of  speech  defects 

When  we  add  to  these  considerations  the  fact  that 
the  number  of  stutterers  exceeds  the  combined  num- 
ber of  deaf,  blind,  and  insane  (for  whom  all  civilized 
governments  have  acknowledged  the  duty  of  making 
liberal  provision),  and  when  we  remember  further  that 
a  large  majority  of  speech  defects  could  be  readily  and 
inexpensively  cured,  the  usual  apathy  assumes  almost 
the  aspect  of  cruelty. 

The  incidence  of  speech  defects  in  school  children 
has  been  investigated  by  Westergaard  and  Lindberg 


SPEECH  DEFECTS 


337 


in  Denmark,  by  Von  Sarbo  in  Hungary,  by  Rouma  in 
Belgium,  and  by  Conradi  in  the  United  States.  The 
following  table  shows  the  most  important  findings  of 
these  investigations:  — 

TABLE  SO 


Country 

Source  of 
data 

Number  of 
children 

with 
speech 

Per  cent 
stutter- 

Name  of 
investigator 

defects 

Denmark 

34,000 

2.2 

.61 

Westergaard 

Denmark 

(  Country 
I  Cities 

212,000 
85,000 

: 

.9 

.74 

f  Lindberg 

Hungary 

(  Cities  and 
I      Towns 

231,000 

1.02 

Von  Sarbo 

Belgium 

Cities 

14,235 

11.5 

1.4 

Rouma 

United 

States 

Cities 

87,440 

2.46 

.87 

Conradi 

If  Conradi's  statistics,  which  were  collected  in  Mil- 
waukee, Cleveland,  Louisville,  Albany,  Springfield, 
and  Kansas  City,  are  representative  for  the  United 
States,  then  our  school  population  contains  about 
a  half-million  children  with  speech  defects,  nearly 
200,000  of  whom  are  stutterers. 

All  the  authorities  agree  that  speech  defects  are 
much  more  common  with  boys  than  with  girls,  the 
ratio  usually  being  about  3  to  1.  The  following  expla- 
nations, none  altogether  satisfactory,  have  been  sug- 
gested by  various  writers  to  account  for  this  superi- 
ority of  girls:  (1)  The  greater  amount  of  language 
correction  and  instruction  which  girls  receive  as  a 
result  of  their  more  intimate  relations  with  the  mother 
during  childhood.  (2)  The  relatively  quiet  and  unex- 
citing mode  of  life  to  which  girls  are  accustomed. 


338    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

(3)  The  preponderance  of  the  costal  type  of  breathing 
with  girls.  (4)  The  innate  superiority  of  the  girls  in 
grace  and  accuracy  of  physical  movement  in  general, 
seen  also  in  their  superiority  over  boys  in  writing, 
drawing,  and  other  hand-work,  and  in  the  smaller 
amount  of  left-handedness.  (5)  The  phylogenetic 
explanation  that  the  domestic  life  which  woman  has 
led  since  the  most  primitive  times  has  given  her  oppor- 
tunity for  more  continuous  practice  of  the  speech 
function  than  has  been  the  case  with  man.  Observa- 
tion (4)  is  probably  a  correct  one,  but  leaves  the  funda- 
mental difference  in  the  physical  dexterity  of  the  sexes 
unexplained.  The  phylogenetic  explanation  need  hardly 
be  taken  seriously. 

The  terminology  of  speech  defects  is  poorly  defined 
in  the  English  language.  The  main  defects,  how- 
ever, are  two  in  number,  designated  in  German  as 
"Stammeln"  and  "Stottern";  in  French  as  "blesite" 
and  "  begaiement."  Both  the  English  terms  "stut- 
tering" and  "stammering"  correspond  to  the  Ger- 
man "Stottern"  and  the  French  "  begaiement,"  but 
"Stammeln"  and  "blesite"  have  no  exact  equivalent 
in  our  language.  "Lisping"  is  coming  slowly  into  use 
as  the  technical  equivalent  of  the  latter  terms,  but  in 
popular  language  is  usually  restricted  to  that  defect 
which  consists  in  the  substitution  of  the  th  sound  for 
*  or  z. 

Lisping 

Lisping  is  the  most  common  speech  defect,  especially 
Vi  the  lower  grades  and  the  pre-school  period.  It 


SPEECH  DEFECTS 


includes  the  inability  to  pronounce  certain  letters  or 

combinations  of  letters,  and  the  tendency  to  omission, 

transposition,  substitution,  or  slurring-over  of  sounds. 

It  is  found  to  greater  or  less  degree  in  the  speech  of  all 

young  children  and  constitutes  the  most  characteristic 

feature  of  "baby  talk."  It  may  be  considered  abnor- 

mal only  when  it     % 

noticeably  persists 

beyond  the  age  of 

5  or  6  years.    The 

frequency,   as  we 

should     naturally 

expect,    decreases 

rapidly  in  the  up- 

per grades  of  the 

school. 

The  accompany- 
ing chart  from 
Rouma  (22)  shows 


14 
13 
12 
11 
10 
9 
8 
7 
6 
5 
4 
3 

ft 

1 

\ 

> 

V 

\ 

z 

\ 

V 

\ 

\ 

X 

%v 

\ 

N 



v 

\ 

\<J. 
'*% 

\Sp 

\ 

> 

-__ 

\ 

SI 

UTTERI 

<Q           ^ 

-"-•^ 

s 

e°22-- 

*P 

\ 

N 

Percentage  of  children  lisping  or  stuttering  in  the 
first  six  grades.    (After  Rouma.) 


for  boys  and  girls 
separately  the 
gradual  decrease  in 

the   percentage    of 

lisping  during  the 

first  six  grades.    The  investigation  included  15,846 

children. 

The  undue  persistence  of  lisping  may  be  due:  (1)  to 
lack  of  practice  in  the  proper  use  of  the  articulatory 
organs  due  to  bad  models  in  the  child's  language  envi- 
ronment; (2)  to  weakness  of  the  auditory  center;  (3)  to 


340    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

incomplete  development  of  the  speech  organs;  (4)  to 
anatomical  abnormalities  of  teeth,  lips,  tongue,  jaws, 
soft  or  hard  palate,  nasal  or  pharyngeal  cavities,  etc. ; 
or  (5)  to  a  general  deficiency  of  the  motor  centers.  The 
above  factors  may  be  operative  in  different  combina- 
tions, and  only  a  careful  clinical  study  of  the  individual 
child  will  indicate  the  treatment  necessary  for  a  cure. 
Some  of  the  lighter  cases  seem  to  be  due  either  to  a 
failure  accurately  to  discriminate  speech  sounds,  or 
else  to  carelessness  or  haste  in  their  reproduction. 

Teachers  meet  all  degrees  of  lisping,  ranging  from  a 
mild  lisp  to  the  most  complicated  substitutions,  omis- 
sions, and  transpositions.  Extremes  of  the  latter, 
known  as  "idioglossia,"  may  bear  so  little  resemblance 
to  the  mother  tongue  as  to  be  mistaken  for  an  entirely 
original  language.1 

Stuttering 

Stuttering,  or  stammering,  is  the  spasmodic  repeti- 
tion of  the  initial  sound  of  a  word  or  syllable.  The 
speech  mechanism  employs  three  sets  of  muscles: 
those  of  (1)  respiration,  (2)  vocalization,  and  (3)  artic- 
ulation. All  of  these  must  function  together  in  the 
most  delicate  coordination  if  normal  speech  is  to  be 
produced.  The  incoordination  of  stuttering  involves  a 
cessation  or  interference  of  the  respiratory  movements, 
together  with  excessive  innervation  of  the  vocal  mus- 
cles and  a  spasmodic  contraction  of  the  articulatory 

1  For  an  interesting  description  of  idioglossia  the  reader  is 
referred  to  chapter  xxi,  reference  8. 


SPEECH  DEFECTS  841 

muscles.    The  excessive  inneryation,  or  hyperphonia, 
is  perhaps  the  chief  feature. 

Stuttering  is  by  far  the  most  important  of  the  speech 
defects  and  deserves  a  more  extended  treatment  than 
is  here  possible.  Unlike  lisping,  its  frequency  increases 
from  grade  to  grade,  at  least  up  to  the  age  of  10  or  11 
years.  Rouma  found  an  increase  of  200  per  cent  from 
the  first  to  the  fourth  grade  (22).  From  the  investiga- 
tions of  Denhart,  Sikorsky,  Mygind,  and  Oltuszewski,1 
it  appears  that  a  large  proportion  of  the  cases  of  stut- 
tering are  contracted  before  the  age  of  6  years  and 
nearly  all  the  remainder  before  the  age  of  14. 

The  results  of  Oltuszewski  for  age  of  onset  are  typi- 
cal. Of  535  cases  reported  by  him,  7  began  at  2  years, 
50  at  3, 67  at  4,  64  at  5,  47  at  6,  32  at  7, 39  at  8, 16  at  9, 
24  at  10, 6  at  11, 6  at  twelve,  7  at  13, 2  at  14,  and  a  total 
of  only  6  from  14  to  21  years.  The  lower  grades  are, 
therefore,  the  most  crucial  as  regards  the  development 
of  the  disease,  though  the  onset  of  puberty  frequently 
brings  about  the  aggravation  of  cases  which  already 
exist. 

Causes  of  stuttering 

The  influences  causing  or  predisposing  to  stuttering 
may  be  grouped  into  six  classes :  — 

(1)  The  reflex,  including  adenoids,  enlarged  tonsils, 
defective  teeth,  etc.  Of  these,  adenoids  are  the  most 
important  and  are  found  with  from  35  to  40  per  cent  of 
all  stutterers.  Dr.  Bresgen  thinks  that  nasal  or  pharyn- 
geal  obstructions  are  at  the  bottom  of  nearly  all  speech 
1  Cited  by  Conradi,  reference  3. 


842    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

defects.  He  thinks  that,  besides  offering  resistance  to 
the  sound  waves,  such  obstructions  render  less  easy 
the  use  of  the  muscles  which  are  called  into  activity  for 
phonation  and  articulation.  This  brings  other  muscles 
into  requisition  and  leads  to  faulty  coordination. 

(2)  General  weakness,  including  low  muscular  tone 
due  to   malnutrition,    illness,    overwork,   etc.     The 
ansemic   are   especially    subject   to   the    defect.     Of 
Mygind's  200  cases,   18  followed  acute  illnesses,  — 
measles,  scarlet  fever,  pneumonia,  whooping-cough, 
diphtheria,  and  mumps,  named  in  order  of  frequency. 
School  overpressure,   worry,  deprivation  from  fresh 
air,  and  insufficient  exercise  are  often  unmistakable 
factors. 

(3)  Psychical  causes,   including  shock,   imitation, 
morbid  fear,  hysteria,  etc.    Baginsky  and  Gutzmann 
think  that  imitation  is  the  most  common  cause  of 
stuttering.    One  case  is  cited  where  a  teacher  with 
60  pupils  had  one  stuttering  pupil  at  the  beginning  of 
the  school  year  and  five  at  the  end.   A  severe  shock, 
such  as  a  blow  on  the  head  or  other  physical  injury, 
sometimes    produces    temporary    speechlessness    fol- 
lowed by  stuttering.   Agonizing  fright  may  act  in  the 
same  manner.    Out  of  535  cases  analyzed  by  Sikorski, 
23  are  attributed  to  fright,  47  to  injury,  and  30  to 
imitation.   The  influence  of  imitation  can,  of  course, 
never  be  weighed  with  absolute  accuracy  because  of 
the  difficulty  of  ruling  out  all  other  possible  factors. 

(4)  Heredity.   All  are  agreed  that  heredity  plays  a 
large  part,  a  majority  of  investigators  assigning  it  first 


SPEECH  DEFECTS  848 

rank.  Coen  finds  evidence  of  inheritance  with  26^  per 
cent,  Mygind  with  42  per  cent,  Altuszuski  with  45  per 
cent,  Sikorski  with  73  per  cent,  and  Arndt  with  77^ 
per  cent.  The  last  mentioned  authors  have  used  the 
term  "heredity"  hi  a  very  broad  sense,  including 
evidence  of  all  kinds  of  neurotic  diseases  hi  even  dis- 
tant branches  of  the  family.  Among  Mygind's  200 
cases,  84  were  found  who  had  a  total  of  124  stuttering 
relatives.  Of  the  latter,  62  sustained  the  relation  of 
brother  or  sister  to  the  patients.  Out  of  the  200,  32  had 
a  total  of  36  relatives  who  had  suffered  epilepsy  or 
other  convulsions.  Of  the  200  cases  58  had  relatives  to 
the  number  of  73  who  had  suffered  "nervousness," 
neurasthenia,  hysteria,  or  nervous  headache  (migraine). 
Even  when  the  immediate  causes  are  especially  promi- 
nent (fright,  physical  injury,  illness,  worry,  fatigue, 
imitation,  etc.),  probably  in  most  cases  these  operate 
in  conjunction  with  a  neuropathic  constitution. 

The  kinship  of  speech  defects  to  other  neuroses  is 
also  indicated  by  the  fact  that  they  are  excessively 
prevalent  among  retarded  and  mentally  defective  chil- 
dren. Rouma  found  lisping  about  twice  as  frequent 
and  stuttering  about  three  times  as  frequent  among 
the  retarded  as  among  normals,  while  feeble-minded 
children  showed  about  seven  times  the  normal  fre- 
quency for  stuttering.  Miss  Town's  study  of  the 
language  development  of  135  imbeciles  showed  that 
only  14.7  per  cent  of  the  low-grade  cases  were  entirely 
free  from  lisping  or  stuttering,  38  per  cent  of  the 
middle  grade,  and  45  per  cent  of  the  high  grade  (26), 


344    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

(5)  Pedagogical  maltreatment,  such  as  ill-advised 
phonic  drills  and  other  faulty  methods  employed  in 
the  teaching  of  elementary  reading.  No  statistics  are 
available  on  this  point,  although  it  is  one  that  has 
been  repeatedly  urged.  Dr.  A.  Melville  Bell  and  Dr. 
Hartwell  have  charged  the  schools  with  being  the 
"breeding-ground  of  the  stuttering  habit,"  and  have 
laid  the  blame  largely  on  "misguided  methods  of 
instruction  in  reading  and  speaking."  As  pointed  out 
by  Huey,1  prevalent  methods  in  phonics  and  in  teach- 
ing to  pronounce  and  to  read  aloud  call  the  child's 
attention  too  much  to  the  "how"  of  utterance  and 
tend  to  produce  a  "mouth  consciousness"  which  in- 
terferes with  a  process  which  was  meant  to  function 
automatically.  The  coordination  once  established,  the 
further  consciousness  stays  away  from  the  process  the 
better.  Its  intervention  produces  nervousness,  awk- 
wardness, and  embarrassment,  and  is  likely  to  balk 
the  coordination  completely.  Work  in  phonics  need 
not  be  excluded  from  elementary  instruction,  but  it 
should  be  limited  to  well-regulated  drill  for  the  cor- 
rection of  defective  speech  and  to  the  necessary  asso- 
ciation in  the  child's  mind  of  certain  of  the  more  diffi- 
cult sounds  with  their  language  equivalents. 

The  influence  of  the  nagging,  sarcastic  teacher  is 
still  more  serious.  The  cause  of  stuttering  is  as  much 
psychical  as  physical,  and  often  has  its  roots  in  a  mor- 
bid fear,  or  speech  timidity,  produced  by  the  teacher's 
severity.  Rapid-fire  questioning,  compulsory  answers, 
1  Psychology  and  Pedagogy  of  Reading,  p.  598. 


SPEECH  DEFECTS  345 

overpressure,  and  the  like,  are  other  school  factors  in 
the  manufacture  of  speech  defects. 

(6)  Interference  with  normal  left-handedness.  Al- 
though it  has  long  been  believed  that  training  left- 
handed  children  to  the  use  of  the  right  hand  is  likely 
to  produce  disturbances  of  the  motor  mechanism  of 
speech,  it  remained  for  the  painstaking  investigation  of 
Ballard  (2)  to  establish  the  point  beyond  controversy. 

Three  separate  studies  were  made  by  Ballard.  The 
first  was  by  means  of  a  questionnaire  addressed  to  the 
teachers  of  13,189  London  children.  Of  these  children, 
12,644,  or  about  97  per  cent,  were  dextrals  (i.e.,  right- 
handed)  ;  while  the  remaining  545,  or  3  per  cent,  were 
sinistrals  (left-handed  by  preference).  Of  the  545 
normally  left-handed  children,  399  had  been  required 
to  learn  to  write  with  the  right  hand.  These  Ballard 
calls  "dextro-sinistrals."  The  proportion  of  stutter- 
ing children  among  the  pure  sinistrals  (left-handed 
children  who  were  permitted  to  write  with  the  left 
hand),  was  1.1  per  cent;  among  the  dextro-sinistrals, 
it  was  4.3  per  cent.  Requiring  left-handed  children  to 
use  the  right  hand  thus  multiplied  the  number  of 
stutterers  in  this  group  by  almost  four. 

Ballard's  second  study  of  the  relation  between 
dextro-sinistrality  and  speech  defects  concerned  944 
mentally  defective  children.  Of  the  882  dextrals,  14, 
or  1.6  per  cent,  were  stutterers;  of  the  dextro-sinistrals, 
nearly  20  per  cent.  In  this  case,  therefore,  training  in 
right-handedness  multiplied  the  chances  of  stuttering 
by  twelve. 


346    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

The  third  study  was  still  more  decisive.  In  this, 
Ballard  made  personal  examinations  of  all  the  sinis- 
trals  (322  in  number)  found  among  11,939  children, 
8  to  14  years  of  age.  Of  the  322,  271  had  been  required 
to  write  with  the  right  hand.  Of  these,  46  stuttered  at 
the  time  and  24  had  stuttered  previously  and  recov- 
ered, or  25.8  per  cent  in  all.  Of  the  51  sinistrals  who 
had  been  permitted  to  use  the  left  hand,  not  one  stut- 
tered. The  proportion  of  stutterers  among  dextro- 
sinistrals  was,  in  this  investigation,  about  eighteen 
times  as  great  as  among  pure  dextrals. 

Accepting  the  latter  figures  as  the  basis  for  our  com- 
putation, it  would  appear  that  not  far  from  one  third 
to  one  half  of  the  stuttering  among  London  school 
children  is  produced  in  the  effort  to  make  right- 
handed  children  out  of  those  who  are  normally  left- 
handed.  At  least  we  are  justified  in  concluding  that 
the  attempt  to  do  this  increases  many  times  the  lia- 
bility of  stuttering. 

The  physiological  mechanism  responsible  for  the 
relation  between  "handedness"  and  speech  control  is 
not  sufficiently  understood  to  warrant  a  discussion  of 
the  various  explanatory  theories  which  have  been 
advanced.  The  fact  that  the  relationship  exists  is 
sufficient  for  practical  purposes.  Left-handed  children 
should  remain  left-handed,  for  writing  at  least.  The 
slight  advantages  which  would  accrue  from  a  change 
are  entirely  outweighed  by  the  dangers  to  speech. 

In  passing,  it  is  interesting  to  note  that  left-handed- 
ness  is  twice  as  common  among  boys  as  among  girls, 


SPEECH  DEFECTS  347 

and  since,  therefore,  an  absolutely  larger  number  of  left- 
handed  boys  than  left-handed  girls  are  made  to  write 
with  the  right  hand,  this  may  account  in  part  for  the 
sex  differences  among  stutterers. 

Whether  other  motor  activities  have  the  same  effect 
as  writing  is  not  certainly  known.  Ballard  believes, 
however,  that  the  chief  danger  lies  hi  the  attempt  to 
change  the  handwriting. 

The  treatment  of  stuttering 

In  whatever  way  stuttering  has  been  caused,  it  is 
curable  in  at  least  nine  cases  out  of  ten.  The  work  in 
foreign  countries  has  demonstrated  this  abundantly. 
The  fact  that  a  few  stutterers  recover  spontaneously 
has  contributed  to  the  neglect  of  curative  treatment. 
To  adopt  the  waiting  policy  with  stuttering  is  no  more 
justifiable  than  the  omission  of  open-air  treatment  of 
tuberculosis.  Stuttering,  like  bad  grammar,  tends,  if 
persisted  in,  to  become  confirmed. 

Unfortunately,  the  treatment  of  stuttering  is  almost 
completely  monopolized  by  quacks.  Each  "stutter 
specialist"  boasts  a  secret,  sometimes  copyrighted, 
method.  Outrageous  prices  are  charged  for  a  kind  of 
treatment  which  is  anything  but  scientific,  and  which, 
while  curing  some  cases,  leaves  others  in  a  worse  con- 
dition than  before. 

What  could  the  school  do  for  stuttering  children? 
The  admirable  study  reported  by  G.  Rouma  (23)  sum- 
marizing the  educational  efforts  in  behalf  of  stutterers 
in  European  schools,  affords  an  authoritative  answer 


848    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

to  this  question.  For  many  years  the  larger  cities 
of  Germany,  Austria,  Switzerland,  and  some  other 
European  countries  have  conducted  special  schools 
for  the  benefit  of  stutterers.  Several  types  of  such 
schools  may  be  distinguished:  — 

(1)  The  school  vacation  colony.    Zurich,  for  ex- 
ample, conducted  such  a  school  in  1899.  The  school, 
which  was  attended  by  21  children,  met  daily  in  a  for- 
est near  the  city.  The  morning  hours  were  devoted  to 
language  exercises,  breathing  lessons,  etc.,  while  the 
afternoon  was  given  over  to  games,  tramps,  and  other 
forms  of  physical  recreation.   Though  the  school  lasted 
only  three  weeks,  several  were  cured  and  all  were 
improved.    Since  then,  Zurich  has  conducted  an  all- 
summer  school  for  stutterers  with  a  daily  session  of 
three  hours.   In  the  summer  of  1902-03  the  school 
was  attended  by  194  children.  At  the  close  of  vaca- 
tion, 146  were  entirely  cured  and  all  the  others  except 
two  were  improved.    This  type  of  school  is  especially 
valuable,  for  the  reason  that  the  stuttering  child  is 
so   often   weak,   nervous,   anaemic,   and  in  need  of 
general  physical  upbuilding. 

(2)  After-school  lessons.   This  is  the  type  of  school 
most  in  vogue  at  present  in  the  countries  of  Europe. 
The  exercises  last  about  an  hour  each  day,  and  are 
given  by  a  teacher  who  has  had  special  training  for  the 
work.    The  method  usually  commends  itself  to  the 
school  authorities  because  it  does  not  interfere  with 
the  pupil's  regular  school  lessons,  but  it  is  open  to 
criticism  in  that  it  comes  at  a  period  when  the  patient 


SPEECH  DEFECTS  349 

is  already  fatigued.  Moreover,  it  interferes  with  the 
recreation  and  exercise  so  much  needed  by  most  stut- 
terers. Still  another  disadvantage  is  that  when  the 
treatment  is  made  such  an  incidental  matter,  it  does 
not  always  enlist  the  enthusiasm  and  voluntary  effort 
so  necessary  in  overcoming  the  defect. 

(3)  Treatment  within  school  hours.    This  is  the 
method  which  has  been  employed  in  Berlin  since  1901, 
and  throughout  Hungary.   Like  the  special  classes  of 
type  (2),  these  also  meet  daily,  usually  for  one  hour, 
and  are  ordinarily  limited  to  a  maximum  of  twelve 
pupils.    Practically  all  the  stuttering  children  in  the 
cities  of  Hungary  are  treated  in  this  way. 

In  Berlin,  Brussels,  and  Buda-Pesth,  schools  of 
orthophonics  are  conducted  every  year  for  the  purpose 
of  training  teachers  in  the  art  of  curing  speech  defects. 
Hungary  has  over  two  hundred  teachers  equipped  for 
the  educational  treatment  of  stutterers.  These  are 
nearly  always  regular  teachers  who  receive  an  addi- 
tional salary  for  the  special  work  and  are  excused  from 
a  part  of  their  other  teaching  duties. 

(4)  A  few  European  cities  have  established  all-day 
special  schools  for  stutterers.     These,  hi  the  opinion 
of  Rouma,  are  the  ideal  kind,  because  they  allow  a 
more  thorough  treatment   than  is  possible  by  any 
other  procedure.  All  the  work  of  such  a  school  can  be 
adapted  to  the  special  needs  of  the  patients,  and  the 
personal  relations  of  teacher  and  pupil  have  time  to 
become  firmly  established.  Schools  of  this  type  recog- 
nize that  stuttering  is  not  merely  a  defect  of  speech, 


350    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

but  that  it  involves  usually  an  extended  zone  of  nerv- 
ous defectiveness.  They  are  often  not  feasible,  how- 
ever, except  in  the  more  thickly  populated  cities,  for 
the  reason  that  it  is  necessary  for  some  of  the  pupils  to 
travel  long  distances  to  attend  them.  Another  objec- 
tion sometimes  made  to  this  method  of  treatment  is 
that  removal  of  the  stuttering  child  from  association 
with  normal  children  is  likely  to  accentuate  his  con- 
sciousness of  defect  and  in  this  way  retard  recovery. 
In  actual  practice,  segregation  does  not  seem  to  have 
this  effect.  Instead,  in  the  opportunity  it  gives  for 
emulation  and  class  spirit,  together  with  the  release  it 
affords  from  the  atmosphere  of  criticism  which  so  often 
oppresses  the  stuttering  child  when  taught  with 
normals,  the  special  all-day  class  has  distinct  and  im- 
portant advantages. 

Schools  of  all  the  types  above  mentioned  are  remark- 
ably successful.  As  a  rule,  recovery  is  complete  within 
four  or  five  months,  and  only  rarely  does  a  case  prove 
entirely  intractable.  When  a  relapse  occurs,  as  some- 
times happens,  the  child  is  given  a  second  course  of 
treatment,  or  even  a  third  if  necessary.  Because  stut- 
terers are  likely  to  be  misunderstood,  badgered,  and 
otherwise  nervously  maltreated  at  home,  it  has  been 
found  helpful  to  furnish  parents  with  a  pamphlet  of 
instructions  and  to  urge  in  personal  conferences  that 
they  adopt  an  encouraging  and  sympathetic  attitude 
toward  the  child.  The  ignorance  of  parents  is  one  of 
the  sad  features  of  the  situation.  Sometimes  they 
inveigh  against  the  treatment,  call  it  useless,  a  waste 


SPEECH  DEFECTS  351 

of  time,  etc.  Others  consider  it  an  unjustifiable  inter- 
ference with  the  ways  of  Providence,  who,  they  think, 
furnished  the  child  with  a  thick  tongue  and  meant  for 
it  to  stutter. 

Treatment  is  most  successful  where  each  case  is 
recognized  as  a  special  problem.  Since  the  defect  does 
not  always  arise  from  the  same  cause,  it  does  not 
always  need  the  same  treatment.  Extensive  informa- 
tion is  gathered  and  recorded  regarding  each  child. 
This  includes  age,  class,  school  progress,  mental  condi- 
tion, condition  of  nose,  throat,  ears,  teeth,  vital  capac- 
ity, motor  ability,  evil  sex  habits,  age  at  which  walk- 
ing and  speech  were  learned,1  age  of  dentition,  record 
of  illnesses  suffered,  condition  of  nutrition,  and  com- 
plete data  regarding  all  nervous  troubles  both  in  the 
child  and  his  immediate  relatives. 

Methods  used  in  the  treatment  of  stuttering 

A  minute  description  of  the  methods  employed  in 
the  treatment  of  speech  defects  would  carry  us  beyond 
the  scope  of  the  present  chapter.  These  will  be  found 
in  the  German  works  of  Gutzmann  and  Liebmann,  and 
in  the  American  volume  by  Scripture. 

No  one  form  of  treatment  has  been  generally  agreed 
upon.  Any  method,  to  be  successful,  must  be  based 
upon  a  scientific  understanding  of  the  essential  nature 
of  the  defect.  The  usual  methods  employed  in  the 
American  private  schools  for  stutterers  are  corned  out 

1  .The  stuttering  child  often  has  a  history  of  retardation  in  one  or 
both  of  these  functions. 


352    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

of  truth  and  fraud  in  the  proportion  of  about  one  to 
nine.  To  use  the  illustration  given  by  Dr.  Hudson- 
Makuen  (12) :  — 

A  stammerer  is  told  to  nod  his  head  whenever  he  speaks, 
and  because  this  procedure  happens  in  this  particular  case 
to  divert  his  attention  sufficiently  long  to  enable  him  to 
speak  freely  for  a  time,  the  quack  thinks  he  has  made  a 
discovery,  and  immediately  evolves  a  theory  and  establishes 
an  institute  with  a  secret  method  which  consists  solely  in 
nodding  the  head  in  unison  with  the  natural  speech.  Another 
advises  beating  time  with  the  forefinger  or  thumb,  or  with 
the  hand  or  foot  during  the  process  of  speaking,  and  each  of 
these  schemes  has  been  dignified  as  a  "method"  which  is 
dispensed  for  a  consideration  under  bonds  of  secrecy.  There 
is  even  now  a  separate  and  distinct  method  which  charac- 
terizes nearly  every  school  and  teacher  engaged  in  the  work, 
and  these  methods  in  many  instances  amount  to  little  more 
than  tricks. 

The  partial  success  of  such  methods  is  due  to  the 
fact  that  the  stutterer's  trouble  is  to  a  great  degree  a 
mental  one,  —  "a  mental  tic,"  as  one  writer  has  char- 
acterized it.  The  child  stutters  because  he  fears  he  will 
stutter.  It  is  quite  essential  that  the  patient's  self- 
confidence  be  aroused.  He  must  forget  that  it  is  any 
longer  possible  for  him  to  stutter.  Appropriate  speech 
exercises,  proceeding  very  slowly  from  the  easiest  to 
the  more  difficult,  and  adapted  to  suit  the  needs  of  the 
individual  case,  gradually  overcome  timidity  and  dis- 
sipate the  language  obsessions.  As  stated  by  Makueo 
(13):- 

If  he  has  weak  will  power,  we  must  show  him  how  to 


SPEECH  DEFECTS  353 

strengthen  it.  If  he  lacks  the  faculty  of  attention  or  con- 
centration, we  must  show  him  how  to  acquire  it.  If  he  has 
grown  morbidly  introspective  and  self-conscious,  he  must 
be  shown  how  to  overcome  this  condition.  If  he  is  suffering 
from  fixed  ideas  and  obsessions,  if  he  has  become  neuras- 
thenic or  psychasthenic,  as  many  of  them  have,  he  must  be 
cured  of  these  diseases  before  he  can  possibly  be  cured  of  his 
speech  malady.  In  other  words,  he  must  learn  to  control 
himself  before  he  can  hope  to  control  his  speech. 

Correct  habits  of  respiration  have  to  be  learned,  for 
as  a  rule  the  stutterer  has  not  learned  how  to  breathe 
properly.  Although  adenoids,  enlarged  tonsils,  im- 
pacted teeth,  etc.,  should  always  be  carefully  attended 
to,  it  should  be  understood  that  stuttering  is  not  pri- 
marily an  affection  of  the  tongue,  lips,  palate,  or 
pharynx.  The  stutterer's  speech  is  faulty  in  every  par- 
ticular. His  whole  nervous  system  is  likely  to  be  at 
fault.  He  may  "stutter"  in  his  emotions,  his  thinking, 
and  his  willing.  The  trouble  is  more  central  than  pe- 
ripheral. The  treatment  must  have  for  its  purpose  a 
reeducation  of  the  individual's  speech  habits,  the  gen- 
eral upbuilding  of  his  physical  health  and  the  improve- 
ment of  his  mental  condition. 

Stuttering  is  more  an  educational  than  a  medical 
problem.  The  contention  sometimes  voiced,  that  the 
disease  is  one  which  can  be  successfully  and  legally 
treated  only  by  a  physician,  is  an  absurd  and  education- 
ally pernicious  doctrine.  Not  one  physician  in  a  thou- 
sand knows  any  more  about  the  treatment  of  stutter- 
ing than  he  does  about  the  teaching  of  Sanskrit.  It  is 
essential,  however,  that  stutterers  be  kept  under  close 


854    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

medical  supervision  for  the  improvement  of  general 
health  and  for  the  treatment  of  specific  physical  de- 
fects. The  actual  task  of  working  over  the  speech 
habits  of  the  stutterer  can  be  more  successfully  accom- 
plished by  special  teachers  in  the  public  schools  at  only 
a  small  fraction  of  the  expense  that  would  attach  to  the 
prolonged  services  of  a  competent  physician.  Speech 
defectives  have  been  too  long  exposed  to  the  question- 
able practices  of  institutions  conducted  for  gain. 
Wherever  stuttering  is  dealt  with  in  the  European  way, 
it  is  cured  easily,  quickly,  and  at  insignificant  expense. 

It  is  plainly  the  duty  of  our  normal  schools  to  give 
the  special  training  needed  for  this  work.  If  at  least 
one  normal  school  in  each  State  offered  an  annual 
course  in  orthophonia,  we  should  soon  have  the  requi- 
site number  of  special  teachers.  European  experience 
shows  that  the  training  can  be  secured  in  a  course 
extending  over  a  single  year  with  one  or  two  lessons  per 
week.  The  training  should  include  not  only  theory, 
but  also  demonstration  and  practice. 

But  the  classroom  teacher  does  not  need  to  wait  for 
the  educational  machinery  to  move.  With  a  little  time 
and  much  patience  any  sensible  teacher  can  accom- 
plish a  great  deal  in  the  improvement  of  defective 
speech.  The  work  of  Liebmann  proves  that  the  ex- 
tremely elaborate  drills  in  articulation,  enunciation, 
and  breathing  used  by  some  specialists  are  by  no 
means  always  essential  to  success.  The  following 
simple  directions  will  be  found  helpful :  — 

Arrange  with  the  child  to  remain  a  half-hour  after 


SPEECH  DEFECTS  355 

school  three  or  four  times  a  week  for  a  speech  lesson. 
Let  this  consist  largely  of  conversation  in  the  low 
ordinary  tone  of  voice.  Convince  the  child  that  he  will 
be  able  to  overcome  the  defect.  Repeat  this  assurance 
until  it  becomes  an  absolute  conviction.  Stuttering 
will  ordinarily  not  cease  as  long  as  the  fear  of  stuttering 
remains.  Stuttering  is  really  a  speech  phobia.  Embar- 
rassment always  aggravates  it.  The  child  stutters 
because  he  is  convinced  he  will  stutter.  He  sings  nor- 
mally; hence  the  trouble  does  not  lie  in  the  speech 
organs  themselves,  but  in  their  control.  Control  is 
balked  by  emotional  stresses,  or  "repressed  emotional 
complexes."  The  stutterer  is  tense.  The  followers  of 
Freud  claim  that  stuttering  is  always  a  form  of  anxiety 
neurosis.  The  patient  must  be  freed  from  the  morbid 
anxieties  which  have  their  seat  in  the  subconscious  life. 
Sometimes  the  whole  character  needs  to  be  reformed. 
The  patient,  being  oversensitive,  may  be  suspicious  of 
others,  always  on  the  lookout  for  signs  of  unfriendli- 
ness. He  must  be  taught  to  take  a  reasonable  attitude 
toward  his  defect  and  toward  people.  Disagreeable 
experiences  which  have  been  repressed  and  embedded 
in  the  subconscious  life  should  be  dug  up  and  recon- 
ciled with  the  daylight  of  consciousness.  The  stutterei 
is  a  victim  of  internal  mental  conflicts.  He  is  nearly 
always  subject  to  doubts,  scruples,  hesitation,  etc. 
As  Freud  and  Appelt  have  shown,  these  may  be  dissi- 
pated by  the  methods  of  psychoanalysis.  It  appears, 
however,  that  any  kind  of  treatment  will  accomplish 
the  same  result  which  encourages  self-confidence, 


356    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

fosters  reasonableness,  and  loosens  the  inhibitions. 
The  stutterer  must  learn  how  to  relax. 

The  fear  of  stuttering  can  only  be  relieved  by  a  little 
experience  with  successful  speech.  The  foundation  for 
this  can  be  laid  in  simple  exercises  in  singing.  The 
patient  is  thus  convinced  that  untrammeled  enuncia- 
tion is  possible  to  him.  Exercises  in  repeating  easy 
sentences  are  also  helpful.  As  self-confidence  grows, 
these  may  be  replaced  by  declamation.  Always  en- 
courage the  child.  Call  his  attention  to  the  slightest 
sign  of  improvement.  Dwell  on  successes;  lead  him  to 
forget  the  failures. 

In  the  child's  reading  and  conversation,  cultivate 
expressiveness  and  melody.  The  stutterer,  as  has  been 
shown  by  the  researches  of  Scripture,  jerks  out  his  sen- 
tences almost  hi  a  monotone.  Such  a  sentence  as 
"How  do  you  do?"  is  droned  out  in  an  uninflected 
tone  which  may  be  represented  as  follows:  — 


FIG.  23 

Line  indicating  the  monotony  of  the  stutterer's 
voice.    (After  Scripture.) 

The  melody  drill  should  be  kept  up  until  the  child  can 
say:  — 


you 

FIG.  24 

Line  indicating  how  the  normal  voice  should 
rise  and  fall  in  speakintr  the  phrase  "How 
do  you  do  ?  "  (After  Scripture.) 


SPEECH  DEFECTS  357 

Further  details  as  to  methods  of  curing  stuttering, 
together  with  elaborate  exercises  and  directions  will  be 
found  in  the  excellent  book  by  Scripture,  which  should 
be  in  the  hands  of  every  teacher  who  has  a  stuttering 
child  in  her  class. 

The  treatment  proper  should  not  be  given  in  the 
presence  of  other  children,  though  two  or  more  stut- 
terers may  be  treated  together.  Encourage  the  child 
to  recite  frequently  in  his  regular  classwork,  and  never 
correct  his  defective  speech  in  the  presence  of  his  class- 
mates, or  even  appear  to  notice  it.  The  stuttering 
child  is  often  among  the  brightest  in  the  class.  Take 
care  to  see  that  he  lives  up  to  his  best  level  of  per- 
formance. Do  not  permit  him  to  fail  even  in  unim- 
portant matters,  where  it  can  be  avoided.  Show 
interest  and  confidence  in  him  as  regards  all  sorts  of 
things,  in  school  and  out.  If  partiality  in  a  teacher  were 
ever  forgivable  it  would  be  in  the  case  of  the  timid 
stutterer.  It  is  also  well  to  talk  with  the  parents,  both 
to  explain  your  efforts  in  the  child's  behalf  and  to 
urge  their  cooperation.  Without  alarming  them  with 
exaggerated  statements  regarding  the  seriousness  of 
the  defect,  explain  clearly  the  handicaps  which  it 
involves. 

The  prevention  of  stuttering 

The  best  time  to  cure  stuttering  is  before  it  begins. 
It  is  important,  therefore,  that  every  teacher  have 
some  knowledge  of  speech  disturbances  and  the  hy- 
giene of  the  voice.  She  should  understand  that  worry, 
embarrassment,  and  excitement  are  important  imme- 


358    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

diate  causes  of  speech  defects.  In  the  words  of  Conradi 
(3):  "If  the  school  is  a  place  of  nervous  tension;  if  the 
child  is  constantly  worried  with  abstractions  ill-fitted 
for  the  child  mind;  if  it  is  asked  to  express  its  confused 
ideas  under  the  eye  of  an  ever  critical  teacher  who 
conceives  of  her  day's  work  as  six  long  hours  of  weari- 
some labor  —  we  have  the  ideal  conditions  for  the 
onset  of  functional  speech  disturbances." 

Physical  defectiveness  and  general  health  should  be 
looked  after  with  especial  care  in  the  case  of  weak, 
nervous  children  who  show  any  tendency  to  speech 
defect.  A  life  of  quiet  and  calm  should  be  fostered. 
Self-confidence  should  be  diligently  cultivated,  for  it 
is  the  nervous  child's  chief  defense  against  stuttering. 
To  upbraid  the  child  for  any  imperfection  of  speech 
is  not  only  brutal,  but  is  certain  to  confirm  and  exag- 
gerate the  defect. 

Any  tendency  to  hurried,  blustering  speech  should 
receive  early  attention.  The  success  of  the  "melody 
cure"  in  the  treatment  of  stuttering  suggests  the 
great  importance  of  the  cultivation  of  melody  and 
expressiveness  hi  the  lower  grades  as  a  means  of  pre- 
venting the  onset  of  the  disease. 

At  least  one  fourth  of  the  children  who  enter  the 
first  grade  of  school  have  not  fully  recovered  from  the 
lisping  and  speech  clumsiness  of  childhood.  It  is 
mostly  from  these  pupils  that  the  ranks  of  stutterers 
are  recruited.  For  this  reason,  Rouma  and  others 
have  urged  that  the  first  months  of  the  school  be  given 
over  to  informal  exercises  in  oral  language  designed 


SPEECH  DEFECTS  359 

to  get  the  children  once  for  all  into  correct  habits  of 
speech.  There  is  no  pedagogical  justification  for  the 
anxious  haste  of  the  primary  school  to  teach  children 
to  read.  Moreover,  if  the  informal  oral  work  here 
recommended  were  substituted  for  some  of  the  more 
formal  work  of  reading  and  writing  in  the  early  months 
of  the  first  grade,  the  transition  from  the  free,  play  life 
of  the  kindergarten  to  the  primary  school  would  be 
made  more  easy  and  natural.  If  one  half  of  the  time 
usually  wasted  on  nonsensical  phonic  drills  were 
devoted  to  the  cultivation  of  an  easy  and  pleasing 
conversational  voice  not  only  would  many  cases  of 
stuttering  be  prevented,  but  the  traditional  "Ameri- 
can voice"  would  lose  some  of  its  disagreeable  flavor.1 
We  should  attach  as  much  value  to  the  correction  of 
slovenly  and  disagreeable  speech  as  to  the  correction 
of  spelling,  grammar,  and  manners.  Speech  habits  are 
only  plastic  till  adolescence,  and  the  responsibility 
of  teachers  in  the  cultivation  of  speech  is  therefore 
very  great.  Melody  and  expressiveness  of  utterance 
should  be  an  important  aim  of  the  school.  If  every 
child  were  given  the  treatment  appropriate  to  the 
incipient  stutterer,  no  one  would  suffer  thereby  and 
the  speech  of  even  the  normal  children  would  be 
greatly  improved. 

1  As  characterized  by  Scripture,  the  "American  voice"  has  three 
chief  qualities:  (1)  hardness,  due  to  excessive  innervation;  (2)  the 
drawl,  or  slurring,  due  to  speech  laziness;  and  (3)  nasal  resonance, 
due  partly  to  habit  and  partly  to  catarrhal  conditions. 


860    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

Suggestions  for  observing  speech  defects 
Does  the  child  stutter? 

Does  he  lisp  (substitute  certain  sounds  for  others)? 
Is  the  child  "tongue-tied"? 
Has  baby-talk  persisted  unduly? 
Is  speech  rapid  or  blustering? 
Is  speech  jerky  (staccato)  ? 
Is  speech  slow  or  drawling? 
Is  the  child  unable  to  respond  promptly? 
Is  enunciation  careless  (sounds  slurred  over  or  dropped)? 
Is  speech  indistinct  (words  "chewed")? 
Is  the  voice  high-keyed  or  shrill?   (Indication  of  nervous- 
ness.) 

Does  the  child  speak  in  monotones? 

Has  the  speech  exaggerated  inflection? 

Is  it  too  loud? 

Is  it  too  low  to  be  easily  heard  over  the  room? 

Has  the  voice  a  nasal  quality?  (Adenoids,  etc.) 

Is  there  chronic  hoarseness? 

Has  the  voice  changed?   (Indication  of  puberty.) 

Is  there  abnormal  hoarseness? 

Is  dentition  normal? 

REFERENCES 

*1.  Alfred  Appelt:  Stammering  and  its  Permanent  Cure;  A  Treatise 

on  Psycho- Analytical  Lines.  London,  1911,  pp.  234. 
*«.  P.  B.  Ballard:  "  Sinistrality  and  Speech."    Jour.  Exp.  Fed. 

(London),  1912,  pp.  298-310. 
*3.  Edward  Conradi:  "The  Psychology  and  Pathology  of  Speech 

Development."  Ped.  Sem.,  1904,  pp.  327-80. 
4.  Edward  Conradi:  "Speech  Defects  and  Intellectual  Progress." 

Jour.  Ed.  Psych.,  1912,  pp.  35-38. 
6.  Anton  Elders:  Heilung  des  Stotterns  nach  gesanglichen  Grand- 

satzen.  Leipzig,  1912,  pp.  68. 

6.  P.  H.  Gerber:  Die  Menschliche  Stimme  u.  ihre  Hygiene.  Leip- 
zig, 1907,  pp.  137. 

7.  Godfring:  "Die  Psychische  Beeinflussung  stotternde  Kinder." 
Zt.f.  Schulgea.,  1906.  pp.  317-23. 

*8.  Leonard  Guthrie:  The  Functional  Nenout  Ditordert  of  Child- 
hood.  1909,  pp.  262-94. 


SPEECH  DEFECTS  861 

9.  A.  Gutzmann:  Uebungbuchf.  d.  Hand  des  Schulers.  1911. 14th 

edition. 

*10.  A.  Gutzmann:  Das  Stottern.  Berlin,  1910,  6th  edition. 
*11.  H.  Gutzmann:  Sprachheilkunde.  Berlin,  1912,  2d  edition,  pp. 

646. 
*12.  Dr.  Hudson-Makuen:  "A  Brief  History  of  the  Treatment  of 

Stammering,  with  some  Suggestions  as  to  Modern  Methods." 

Pennsylvania  Med.  Jour.,  December,  1909. 

13.  Dr.  Hudson-Makuen : " The  Treatment  of  Stammering."  Jour. 
Amer.  Med.  Assoc.,  September.  1910. 

14.  Adolf  Kussmaul :  Die  Storungen  der  Sprache.  Leipzig,  1910,  4th 
edition,  pp.  409. 

15.  G.  A.  Lewis:  "Cure  of  Stammering  and  Stuttering."   Amer. 
Phys.  Ed.  Rev.,  1903,  pp.  249-59. 

16.  G.  A.  Lewis:  Practical  Treatment  of  Stammering  and  Stuttering, 
and  a  Treatise  on  the  Cultivation  of  the  Voice.  Detroit,  1902, 
pp.  415. 

*17.  Michael  Levine:  "Preliminary  Report  on  the  Treatment  of 
Stuttering,  Stammering  and  Lisping  in  a  New  York  School." 
Psych.  Clinic,  1912,  pp.  93-106. 

*18.  Albert  Liebmann:  Vorlesungen  iiber  Sprachstorungen.  Berlin, 
1898  to  1909. 

19.  Cortland  MacMahon:  "Curative  Treatment  of  Stammerers." 
School  Hygiene,  1911,  pp.  315-21. 

20.  T.  J.  McHattie:  "The  Educational  Treatment  of  Stammering 
Children."  School  Hygiene,  1911,  pp.  308-14. 

21.  E.  Paulsen:  "Ueber  die  Singstimme  der  Kinder."    Pfliiger't 
Archives,  1895,  pp.  407-76. 

*22.  George  Rouma:  "Enquete  scolaire  sur  les  troubles  de  la  parole 
chez  les  ecoliers  beiges."  Inter.  Mag.  Sch.  Hyg.,  1906,  vol.  II, 
pp.  151-90. 

*23.  George  Rouma:  "L'Organization  de  cours  de  traitement  pour 
enfants  troubles  de  la  parole."  Inter.  Mag.  Sch.  Hyg.,  1907, 
vol.  in,  pp.  116-71. 

*24.  E.  W.  Scripture:  Stuttering  and  Lisping.  1912,  pp.  251.  (The 
most  important  work  on  the  subject  in  English.  Gives  direc- 
tions for  treatment.) 

t5.  Eric  B.  Smith:  "An  Investigation  of  Some  Causes  of  Defective 
Speech  in  Elementary  Schools."    School  Hygiene,  1912,  pp. 
143-54. 
26.  Clara  Harrison  Town:  "Language  Development  in  285  Idiots 

and  Imbeciles."   Psych.  Clinic,  1913,  pp.  229-35. 
t7.  Harry  P.  Weld:  "The  Mechanism  of  the  Voice  and  its  Hy- 
giene." Ped.  Sem.,  1910,  pp.  143-59.  (Pertains  mostly  to  sing- 
ing-) 


CHAPTER  XX 

THE  SLEEP  OF  SCHOOL  CHILDREN1 

SLEEP  and  food  are  two  of  the  most  imperative 
needs  of  the  human  organism.  Each  has  its  educational 
and  economical,  as  well  as  its  physiological  and 
biological,  aspects.  But  while  diet  has  long  received 
a  liberal  share  of  attention  from  economist,  hygienist, 
and  biologist,  the  scientific  study  of  sleep  has  been 
hardly  more  than  initiated. 

Sleep  is  one  of  the  biological  rhythms  stamped  into 
the  organism  by  the  movements  of  the  planet  on 
which  we  live.  To  interfere  unduly  with  such  an  an- 
cient and  physiologically  established  rhythm  would 
theoretically  appear  to  be  an  unsafe  experiment.  It  is 
an  instinct  which  involves  the  entire  body,  and  is  not 
simply  a  function  of  the  brain.  The  brainless  dogs  of 
Golz  and  the  brainless  pigeons  of  Manaceine  exhibited 
the  same  sleep  rhythms  after  the  removal  of  the  cere- 
brum as  before.  Psychiatrists  tell  us  that  many 
mental  disorders  are  preceded  by  protracted  insomnia. 
Loss  of  sleep  has  been  experimentally  shown  to  cause 
a  decrease  in  the  number  of  red  corpuscles,  while  the 
beat  of  the  heart  is  accelerated  to  compensate  for  the 
poverty  of  the  blood.  Far  from  being  a  bad  habit,  as 

1  Written  with  the  assistance  of  Adeline  Hocking,  Stanford 
University. 


THE  SLEEP  OF  SCHOOL  CHILDREN      363 

Girondeau  believed,  sleep  has  been  evolved  as  the  best 
biological  means  of  making  possible  intense  periodic 
activity  of  mind  and  body. 

Besides  acting  to  recharge  the  batteries  of  life,  sleep 
has  a  settling  and  confirmatory  influence  upon  the 
mental  activities  which  precede  it.  To  "sleep  over  a 
problem"  is  a  means  of  transforming  a  chaos  of 
puzzled  mentation  into  order  and  clarity.  The  learn- 
ing processes  which  are  initiated  during  the  work  of 
the  day  take  deeper  root  during  the  hours  of  sleep. 
In  sleep,  life  purposes  may  mature  and  ideals  take 
shape. 

On  the  other  hand,  we  must  avoid  overestimating 
the  hours  of  sleep  necessary.  Sleep  is  but  one  of  the 
many  needs  of  children,  and  it  is  foolish  to  make  it  the 
scapegoat  for  all  kinds  of  physical  and  mental  evils,  as 
hygienists  have  so  often  done.  It  is  possible  that  the 
quantity  of  sleep  is  less  important  than  its  quality, 
and  when  disturbances  of  the  latter  occur,  they  are 
likely  to  be  the  effect  of  the  ill  health  rather  than  its 
cause. 

The  amount  of  sleep  needed 

On  this  point  we  have  a  large  number  of  estimates 
based  upon  opinion,  but  no  certain  knowledge.  The 
theoretical  norms  set  forth  by  Dr.  Duke  have  been 
very  generally  accepted.  Other  noteworthy  stand- 
ards are  those  of  Hertel,  Bernhard,  and  Claparede. 
The  difference  of  opinion  which  prevails  is  shown  in 
Table  31. 


864    THE  HYGIENE  OF  THE  SCHOOL  CHILD 
TABLE  81.    ESTIMATE  OF  SLEEP  NEEDS   (HOURS) 


Age 

5 
to 
6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

Duke  

m 

13 

i»i 

1» 

111 

11 

10i 

10 

10 

91 

9 

Q 

81 

Bernhard.  . 
Hertel  
Clapar&de.  . 
Manaceine  . 
Krollich.... 
Cavanagb  . 
Brown  .... 
Pfaunder  .  . 
Key  

11 
111 

14 
11 

Hi 
11 
11 

11 

101 
111 
11 
11 
12 

11 

101 

111 

11 
11 

11 
10 

101 

11 
11 

10 
101 
10 
10i 

ll\ 

91 
10 
101 

10 
91 
91 
91 
10 

10 
9 
10 

10 

91 
81 
10 

91 
9 
9 

81 
91 

9 
9 
8 
9 

81 

8to7 
0 

8} 
0 

The  above  table  shows  a  difference  of  opinion 
amounting  to  2^  hours  for  the  age  6,  2|  hours  for  age 
7, 2  hours  for  age  8, 2  hours  for  age  9,  etc.  Duke  recom- 
mends as  many  hours  for  age  18  as  Manaceine  for  age 
13;  and  as  many  hours  for  age  14  as  Manaceine  for 
age  10.  Duke's  estimate  for  11  years  equals  Key's  for 
6  years.  In  like  manner,  twenty-nine  medical  officers 
of  English  schools,  who  were  interrogated  by  Acland 
(1),  estimated  the  sleep  needs  of  12-year-old  boys  all 
the  way  from  9  hours  to  more  than  10. 

Several  investigations  have  been  made  of  the  num- 
ber of  hours  children  do  sleep,  though  obviously  we 
cannot  in  this  way  determine  conclusively  how  many 
hours  they  ought  to  sleep.  One  of  the  earliest  of  these 
was  by  Hertel,  who  in  his  study  entitled  "Overpres- 
sure in  the  Schools  of  Denmark  "  presents  sleep  records 
from  3141  boys  and  1211  girls  in  the  schools  of  Copen- 
hagen. These  averaged  about  lOf  to  11  hours  of  sleep 
at  6  years,  the  amount  decreasing  to  9^  hours  at  12 
years,  and  to  about  8^  at  16  years.  Sleep  was  most 
deficient  among  pupils  pursuing  the  arduous  classical 


THE  SLEEP  OF  SCHOOL  CHILDREN       365 


courses,  where  it  often  fell  to  6  or  7  hours.  Acland 
found  that  the  hours  of  "undisturbed  rest"  given  to. 
boys  10  to  13  years  of  age  in  forty  English  boarding- 
schools  ranged  from  8  to  10,  averaging  about  9.  The 
actual  time  of  sleep  must  have  been  somewhat  less 
than  this,  and  was  certainly  far  below  the  amount 
physicians  usually  consider  desirable. 

Important  investigations  of  the  sleep  of  school  chil- 
dren are  those  of  Dr.  L.  Bemhard  (3)  and  Dr.  Alice 
Ravenhill  (14).  The  former  secured  data  from  6551 
German  children  6  to  14  years  of  age,  and  the  latter 
from  6180  English  children  of  about  the  same  ages. 
The  average  amount  of  sleep  for  each  year  is  shown  in 
the  following  table:  — 

TABLE  32.    SLEEP  OF  GERMAN  AND  ENGLISH 
CHILDREN 


Age 

Sleep  in  hours  and  minutes 

6 

7 

8 

9 

10 

11 

12 

IS 

Bernhard 
Ravenhill 

10.20 
10.30 
10.45 

9.50 
10.30 
10.30 

9.25 
9.30 
10.15 

9.20 
9.15 
9.30 

9.10 
9.15 
9.30 

8.55 
8.45 
9.15 

8.25 
8.15 
8.00 

7.50 
8.30  Boys 
7.30  Girls 

Using  his  own  estimate  of  the  amount  of  sleep  which 
children  ought  to  have,  Bernhard  computes  that  the 
sleep  deficiency  among  his  6551  pupils  ranges  from 
about  an  hour  at  the  age  of  7  to  nearly  an  hour  and 
three  quarters  at  14  years.  This  would  represent  a 
total  sleep  loss  per  year  of  over  400  hours  for  the  aver- 
age child  of  6,  and  over  600  hours  for  the  average  child 


866    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

of  14  years.  Miss  Ravenhill,  basing  her  estimate  upon 
the  standards  furnished  by  Dr.  Duke,  finds  an  average 
sleep  deficiency  for  English  children  of  nearly  25  per 
cent;  while  that  for  girls  of  13  years  amounts  to  a 
daily  loss  of  3  j  hours.  Children  of  6  years  were  found 
who  slept  only  7  hours,  and  children  of  12  years,  4  to 
6  hours. 

During  the  year  1911-12  the  writer,  with  the  assist- 
ance of  Miss  Adeline  Hocking,  carried  out  an  investi- 
gation of  the  sleep  of  school  children,  which  had  for 
its  purpose,  (1)  to  ascertain  by  more  careful  methods 
than  had  yet  been  employed  the  hours  of  sleep  of 
children  hi  the  Western  States  of  America;  (2)  to 
discover  what  correlation  exists  between  hours  of 
sleep  and  school  success;  and  (3)  to  find  the  relation  of 
hours  of  sleep  to  social  status,  home  study,  and  the 
•possession  of  typical  "nervous"  traits.  Records  were 
secured  from  2692  children  between  6  and  20  years 
of  age  in  the  California  cities  of  Stockton,  San  Jose, 
Alameda,  and  Los  Gatos;  Tempe,  Arizona;  and  Mon- 
mouth,  Oregon. 

By  means  of  a  carefully  planned  and  uniform  pro- 
cedure data  were  secured  showing  the  exact  time  of 
retiring,  the  approximate  length  of  time  required  for 
going  to  sleep,  the  exact  time  of  waking,  whether 
waking  was  spontaneous,  how  many  other  persons 
slept  in  the  same  room  and  the  same  bed,  and  the 
amount  of  ventilation  in  the  bedroom. 

The  amount  of  sleep  for  these  2692  persons  is  shown 
in  hours  and  minutes  in  the  following  table:  — 


THE  SLEEP  OF  SCHOOL  CHILDREN       367 


TABLE  S3 


Age 

No.  of 
records 

Av.  no.  of 
bra.  of  sleep 

Age 

No.  of 
records 

Av.  no.  of 
hrs.  of  sleep 

6-  7 

37 

11.14 

13-14 

250 

9.31 

7-  8 

147 

10.41 

14-15 

244 

9.06 

8-  9 

218 

10.42 

16-16 

201 

8.54 

9-10 

291 

10.13 

16-17 

167 

8.30 

10-11 

307 

9.56 

17-18 

117 

8.46 

11-12 

282 

10.00 

18-19 

43 

8.46 

12-13 

312 

9.36 

University 
students 

51 

7.47 

The  most  important  fact  in  the  above  table  is  the 
striking  excess  of  sleep  among  these  children  as  com- 
pared with  the  German  and  English  children  of  Bern- 
hard  and  Ravenhill.  This  excess  amounts  for  most 
ages  to  between  one  hour  and  one  hour  and  a  half. 
At  the  same  time  the  sleep  averages  found  in  this 
investigation  fall  from  three  fourths  of  an  hour  to  two 
hours  below  the  theoretical  standards  set  by  Dr.  Duke. 

jfcs      Q  7  8  9          10          11          12          13 


13 

12-30 

12 

11-30 

II 

10-30 

10 

9-30 

9 

8-30 

8 

7-30 


FIG.  26 

Amount  of  sleep  children  actually  receive  compared  to  Duke's  theoretical 
standard 


868    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


These  points  of  difference  are  shown  graphically  hi 

figure  25. 

An  idea  of  the  individual  differences  may  be  gained 

from  figure  26,  which  shows  an  average  difference  of 

three  to  four  between  the  ten  highest  and  ten  lowest 

for  each  age. 

It  is  seen,  therefore,  that  the  average  amount  of 

sleep  received  by  children  in  the  western  part  of  the 

Age  e    7    8   9    10  11  12  13  u  15  16  United  States  very 

greatly  exceeds 
that  for  German 
and  English  chil- 
dren. This  may  be 
accounted  for  by 
the  differences  hi 
climate  and  in  the 

Showing  extreme*  in  amount  of  sleep  secured  at     ' 

different  age*.    (Tenaan  and  Hocking.)  doQr   jj^g  (wnicn 

is  known  to  favor  sleep),  by  the  better  home  environ- 
ment of  our  pupils,  and  by  the  relatively  late  hour  of 
beginning  the  school  day  in  this  country. 

Our  average  would  have  been  still  higher  had  all 
the  children  been  permitted  to  sleep  until  they  awak- 
ened spontaneously.  The  following  table  shows  the 
percentage  hi  each  year  who  had  to  be  awakened:  — 

TABLE  34 

Age  «       7      8       »      10      11      12      19     14      15       16      17       18 

^wlkened      21.2  19  233  19.1   t2.8  20.3  236  247  26    31.6  38.7   89.9  47.7 

The  interesting  fact  here  is  the  rapid  increase  in  early 


THE  SLEEP  OF  SCHOOL  CHILDREN       369 

adolescence  of  the  number  who  did  not  wake  spon- 
taneously, probably  due  to  the  fact  that  a  majority  of 
the  records  above  the  age  of  14  were  from  high-schoo* 
pupils,  who  were  required  to  do  more  evening  worL 
than  the  younger  children. 

Although  it  cannot  be  assumed  that  averages  secured 
in  this  investigation  furnish  absolutely  reliable  norms 
of  the  amount  children  of  various  ages  ought  to  sleep, 
it  is  believed  that  they  are  of  more  value  for  compara- 
tive purposes  than  any  which  have  hitherto  been  avail- 
able. The  averages  of  Bemhard  and  Ravenhill  prob- 
ably show  a  sub-normal  amount  of  sleep,  while  the 
traditionally  accepted  norms  of  Duke  are  certainly 
too  high. 

The  relation  of  sleep  to  intelligence,  to  social  status, 
and  to  nervous  traits 

In  order  to  throw  light  on  these  points,  supplemen- 
tary information  was  secured  from  each  of  1350  out  of 
the  total  2692  individuals.  This  included  the  degree 
of  intelligence  as  estimated  by  the  teacher  on  a  scale 
of  seven,  the  social  status  of  the  home  as  estimated  on  a 
scale  of  four,  the  number  of  "nervous"  traits  possessed 
by  the  child,  and  his  school  success.  School  success  was 
measured  by  the  child's  grades  in  the  different  sub- 
jects received  at  the  end  of  the  previous  quarter  or 
semester.  Correlations  were  then  computed,  for  the 
different  ages  separately,  by  the  well-known  Pearson 
formula. 

In  every  case  it  was  found  that  there  was  practically 


870    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

no  correlation,  either  positive  or  negative,  between 
sleep,  on  the  one  hand,  and  intelligence,  social  status, 
"nervous"  traits,  or  any  school  subject,  on  the  other. 
The  instances  in  which  the  coefficient  of  correlation 
exceeded  +.10  or  —  .10  were  so  few  and  appeared  so 
sporadically  in  the  different  ages  as  to  be  wholly  with- 
out significance.  It  was  even  found  that  the  school 
grades  of  the  pupils  sleeping  the  least  averaged  slightly 
above  those  of  the  ten  sleeping  the  most. 

How  are  we  to  explain  a  result  so  at  variance  with 
current  belief? 

One  interpretation  would  be  that  the  average  child 
receives  more  sleep  than  he  really  needs.  It  has  been 
experimentally  shown  that  sleep  ordinarily  becomes 
superficial  after  four  or  five  hours,  and  it  has  been 
suggested  that  this  period  of  less  effective  sleep  might 
be  considerably  shortened  without  material  loss.  In 
harmony  with  this,  Weygandt's  tests  of  mental  effi- 
ciency seemed  to  indicate,  for  himself,  complete  recov- 
ery from  the  most  difficult  kinds  of  mental  work  after 
five  hours  of  sleep  (19).  On  the  other  hand,  Netscha- 
jeff's  experiments  on  the  relation  between  his  own 
sleep  and  mental  efficiency  during  a  period  of  four 
months  show  that  the  latter  was  affected  by  extremely 
slight  deficiencies  of  sleep.  Further  investigation  is 
urgently  needed. 

A  second  explanation  of  the  lack  of  correlations  is 
offered  by  the  theory  that  quantitative  differences  in 
sleep  may  be  offset  by  qualitative  differences.  If  such 
qualitative  differences  exist,  then  sleep  cannot  be 


THE  SLEEP  OF  SCHOOL  CHILDREN      371 

accurately  measured  in  units  of  time  alone.  The 
observations  of  Gilbert  and  Patrick  (13),  who  for 
experimental  purposes  went  without  sleep  for  ninety 
hours,  showed  that  only  a  small  fraction  of  the  sleep 
lost  (one  third  to  one  sixth)  was  later  made  up,  but 
that  the  sleep  which  followed  the  experiment  was  much 
more  profound  than  usual. 

A  third  explanation  relates  to  "the  factor  of  safety." 
This  may  be  sufficiently  large  to  enable  both  body  and 
mind  for  many  years  to  withstand  with  apparent  suc- 
cess a  real  and  considerable  sleep  deficiency,  while  at 
the  same  time  the  reservoir  of  energy  is  being  insidi- 
ously depleted.  It  would  be  rash  to  infer  that  a  mode  of 
life  is  safe  merely  because  it  does  not  produce  immedi- 
ate and  evident  injury.  The  factor  of  safety  must  be 
kept  intact.  We  want  not  merely  the  strength  to  do 
the  average  work  of  each  day,  but  we  need  to  keep 
the  reservoirs  of  energy  well  supplied,  so  that  we  may 
withstand  the  sieges  of  deprivation,  disease,  accident, 
and  overwork  which  are  almost  inevitable. 

In  the  fourth  place,  the  lack  of  correlation  between 
sleep  and  intelligence  may  be  accounted  for  on  the 
hypothesis  that  the  heightened  brain  activity  which  is 
necessary  for  high-grade  intellectual  processes  involves 
a  kind  of  neural  excitement  which  itself  predisposes 
to  wakefulness.  To  test  this  hypothesis,  sleep  records 
were  secured  from  383  feeble-minded  individuals, 
from  6  to  more  than  60  years  of  age,  in  the  Vineland 
Training  School.1  Figure  27  shows  the  results  for  the 

1  The  writer  is  indebted  to  Superintendent  E.  R.  Johnstone  and  to 
Dr.  H.  H.  Goddard  for  supplying  the  records  for  this  comparison. 


872    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

193  feeble-minded  children  whose  ages  fell  between  6 
and  19  years.   For  sake  of  comparison  the  curve  for 

Hours  our  normal  children 

I2r  ,       , 

is  reproduced. 

X.  It  is  seen  that  th  e 

10  N^>ef ^Z^T^^^^^^^^^^.      feeble-minded  chil- 
9h  —      xS-x^^aiste— 

^— • — s.         dren     sleep    much 

less    than    normal 
children     of      the 


8 


7    8    9  10  11  12  13  14  15  16  17  18  19     S*1116   »ge»   the  fee- 

FIO.  27  ble-minded    adults 

Bleep  of  mentally  def ecti  ve  children  compared  with    mil  r-li      m  <  > r r>      t  Vi  a  n 
that  of  normals.     (Terman  aud  Hocking.) 

normal  adults.    As 

regards  sleep,  the  feeble-minded  retain  throughout  life 
the  characteristics  of  childhood.  Otherwise  there  seems 
to  be  little  relation  between  the  amount  of  sleep  and 
the  grade  of  intelligence. 

As  regards  the  school  child,  in  all  probability,  the 
wisest  course  is  for  us  to  make  the  conditions  such  that 
the  child  will  sleep  as  many  hours  per  day  as  he  wants 
to  sleep.  We  should  avoid  either  abbreviating  or 
unduly  prolonging  the  sleep  beyond  this  standard. 
Liberal  allowance  should  also  be  made  for  individual 
differences.  There  are  probably  physiological  idiosyn- 
crasies which  make  nine  hours  for  one  child  equivalent 
to  eleven  hours  for  another. 

The  conditions  of  children's  sleep 

The  conditions  of  sleep  may  be  roughly  classified 
under  two  headings:  (a)  the  external  or  environmental, 


THE  SLEEP  OF  SCHOOL  CHILDREN      373 


and  (6)  the  internal  or  individual.   Under  the  former 
may  be  considered  such  matters  as  the  following :  — 

(1)  Housing  conditions.    There  is  probably  no  sec- 
tion of  the  country  where  crowding  is  less  common 
than  in  the  Western  States;  but  of  the  2692  children 
who  entered  into  this  investigation,  only  32  per  cent 
have  a  bedroom  to  themselves,  while  16.4  per  cent 
share  the  sleeping-room  with  two  other  persons,  and  9 
per  cent  with  three  or  more. 

(2)  Ventilation.  The  following  table  reveals  the  bed- 
room ventilation  of  our  2692  pupils  for  the  different 
ages.  The  first  column  shows  that  the  number  sleep- 
ing practically  without  ventilation  is  much  smaller  in 
the  later  years.  This  is  no  doubt  partly  the  result  of 
hygiene  instruction  in  the  school. 

TABLE   35 


Ventilation  of  bedrooms 

Age 

No  window 
open 

One  open 

More  than  one 
open 

Open-air 

6 

40.6% 

43.8% 

12.5% 

3.1% 

7 

38. 

52.5 

8. 

1.5 

8 

28.5 

58.1 

9.3 

4.1 

0 

28.4 

56.2 

12.1 

3.3 

10 

24.6 

57.8 

14.5 

3.1 

11 

26. 

56.4 

14.5 

3.1 

12 

19.6 

63.5 

13.6 

3.3 

13 

16.6 

62. 

16.6 

4.8 

14 

10.2 

66.6 

20.8 

2.4 

15 

14. 

69. 

14.6 

2.4 

16 

5.2 

67.8 

25. 

2. 

17 

6.5 

70.4 

18.5 

4.6 

18 

2.5 

78. 

17. 

2.5 

Any  teacher  who  will  go  to  the  slight  trouble  neo« 


874    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

essary  to  make  a  sleep  survey  in  her  school  will 
find  enough,  not  only  to  astonish  her,  but  to  give  her 
some  valuable  suggestions  for  the  teaching  of  practical 
hygiene.  In  this  case  it  was  found  that  47  per  cent  of 
those  sleeping  with  no  windows  open  were  sharing  the 
bedroom  with  at  least  two  other  persons ! 

(3)  Work.    Five  per  cent  of  Ravenhill's  boys  rose 
regularly  before  5  A.M.  for  various  kinds  of  work.  Of 
the  6-year-old  boys,  2  per  cent  were  engaged  in  gainful 
occupations  out  of  school  hours.   This  rose  to  28  per 
cent  at  11  years  and  to  53  per  cent  at  12. l  Almost  any 
teacher  hi  city  schools  above  the  sixth  grade  will  find, 
if  she  takes  the  trouble  to  inquire,  a  certain  number  of 
pupils  in  her  class  who  are  engaged  in  remunerative 
labor  from  10  to  20  hours  per  week. 

(4)  Hours  of  retiring.   Nearly  5  per  cent  of  Raven- 
hill's  6-year-old  children  retire  as  late  as  10  o'clock,  and 
nearly  10  per  cent  of  her  10-year-olds.   The  time  lost 
in  this  way  cannot  be  fully  made  up  in  the  morning 
because  of  the  disturbance  caused  by  the  early  rising 
of  parents,  and  because  of  the  necessity  of  getting  to 
school  at  a  given  hour.   In  other  words,  the  hours  set 
apart  for  the  sleep  of  children  are  not  always  those  best 
adapted  to  insure  a  sufficient  amount.  Even  the  fam- 
ilies who  set  a  reasonably  early  hour  for  the  children 
to  retire  usually  permit  so  many  irregularities  that,  as 
one  writer  puts  it,  "the  law  is  more  observed  in  the 
breach  than  in  the  performance."    Ravenhill  found 

1  In  our  own  study  the  returns  on  this  point  were  unreliable 
because  of  an  unfortunate  wording  of  one  of  the  questions. 


THE  SLEEP  OF  SCHOOL  CHILDREN       375 

that  20  per  cent  at  6  years,  and  40  per  cent  at  13  years, 
were  allowed  one  or  more  irregularities  per  week.  The 
European  custom  of  beginning  school  at  7  to  8  o'clock 
in  the  morning  works  great  hardship,  often  causing  the 
pupil  to  rush  away  to  school  in  nervous  haste  and  with- 
out breakfast.  Nine  o'clock  is  far  better. 

(5)  Vermin.  Medical  examiners  sometimes  find  from 
10  to  40  per  cent  of  the  pupils  of  a  school  affected 
with  vermin.    Needless  to  say,  the  child  who  is  so 
tormented  cannot  secure  normal  sleep.  Other  parasitic 
diseases,   such   as   scabies    ("itch"),  ringworm,  and 
intestinal  worms,  should  be  mentioned  in  this  connec- 
tion. 

(6)  Miscellaneous  conditions.    The  sleep  of  school 
children  is  influenced  in  many  other  ways.  Tempera- 
tures much  above  60  degrees  are  unfavorable  both  to 
quantity  and  quality  of  sleep;  hence  children  sleep 
more  in  the  whiter  than  in  summer.  The  late  sunrise 
of  winter  mornings  exerts  an  influence  in  the  same 
direction.    Humidity  and  atmospheric    pressure  are 
other  factors,  though  their  exact  effects  have  not  yet 
been  determined.    Some  children  sleep  poorly  for  lack 
of  a  bed  or  because  of  insufficient  protection  from  cold. 
Still  others  are  aroused  by  the  din  of  early  street 
noises. 

Internal  conditions  influencing  sleep 

Improper  diet  is  one  of  the  most  important  of  these. 
The  child's  sleep  may  be  disturbed  by  excess  of 
starchy  foods,  unsuitable  cooking,  etc.  The  late 


876    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

dinner,  following  an  inadequate  breakfast  and  cold 
unsatisfying  noonday  meal,  favors  engorgement  of  the 
stomach,  and  is  therefore  unfavorable  to  sleep. 

The  influence  of  tea  and  coffee  upon  sleep  is  a  matter 
of  common  observation.  The  experiments  of  Hollings- 
worth  (8)  on  ten  men  and  six  women,  extending  over 
a  period  of  forty  days,  verify  common  opinion  on  this 
point,  and  show  further  that  the  influence  of  caffeine 
is  in  inverse  proportion  to  the  weight  of  the  subject. 
One  cup  of  coffee  for  the  7-year-old  child  is  therefore 
equivalent  to  three  cups  for  the  average  adult.  Even 
this  may  understate  the  facts,  since  it  is  probable  that 
the  child's  body  does  not  adjust  and  become  habitu- 
ated to  the  evil  effects  of  drugs  as  well  as  the  body  of 
the  adult.  Dr.  E.  B.  Hoag  finds,  from  questioning 
many  thousands  of  school  children,  that  about  80  per 
cent  drink  coffee  or  tea  daily,  and  that  many  young 
children  drink  from  three  to  six  cups  daily.  Hundreds 
of  thousands  of  school  children  in  the  United  States 
are  kept  in  a  constant  state  of  semi-intoxication  by  the 
use  of  coffee  and  tea. 

The  nervous  child  is  notoriously  a  bad  sleeper.  Such 
a  child  is  likely  to  be  obsessed  by  fears,  tormented  by 
absurd  pangs  of  conscience,  excited  by  an  over-active 
intelligence,  or  worried  by  trivial  happenings  which 
would  be  forgotten  by  the  normal  child  in  a  few  min- 
utes. Religion-bred  fears,  fear  of  the  dark,  and  vague 
indefinable  anxieties  haunt  the  evening  hours  of  more 
children  than  most  of  us  suspect;  for  children  learn 
that  it  is  pleasanter  to  bear  many  a  secret  pain  and 


THE  SLEEP  OF  SCHOOL  CHILDREN       377 

sorrow  than  to  hazard  reproof  and  misunderstanding 
by  imparting  them  to  unsympathetic  elders. 

Home  study  robs  many  a  nervous  child  of  the  needed 
margin  of  sleep.  It  not  only  causes  him  to  remain  up 
later,  but  is  likely  to  induce  an  excited  condition  of 
mind  which  is  followed  by  superficial  and  disturbed 
sleep.  Arithmetic  lessons  are  especially  unsuited  for 
home  assignments,  but  because  of  their  quality  of 
definiteness  they  are  just  the  kind  of  homework  with 
which  children  are  most  likely  to  be  burdened. 

Other  common  causes  of  disturbed  sleep  are  ob- 
structed breathing,  eye-strain,  dentition,  earache, 
toothache,  etc. 

In  children  over  eight  years  of  age  night  terrors  are  a 
common  disturbance.  They  are  occasionally  provoked 
by  indigestion,  obstructed  breathing,  or  other  reflex 
irritations,  but  in  most  cases  of  chronic  recurrence  they 
are  associated  with  other  hereditary  nervous  taints, 
notably  migraine.  The  condition  is  then  indicative  of 
general  nervous  instability.  The  child  who  suffers  from 
night  terrors  deserves  special  oversight  on  the  part  of 
parent,  teacher,  and  physician.  Often  it  is  wise  to 
remove  such  a  child  from  school. 

Teaching  children  to  sleep 

That  only  3.1  per  cent  of  the  school  children  in  the 
mild  and  equable  climate  of  California  enjoy  open-air 
sleeping-rooms  suggests  what  remains  to  be  done  in 
this  line  of  instruction. 

The  teacher  should  know  the  poor  sleepers  in  her 


378    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

classes  and  those  who  suffer  night  terrors  or  other 
fears  and  obsessions  which  interfere  with  sleep.  She 
should  know  which  children  drink  coffee,  tea,  and  beer; 
which  ones  sleep  in  crowded  and  ill-ventilated  bed- 
rooms. By  means  of  a  series  of  questions  the  teacher 
ought  every  year  to  make  a  sleep  survey  of  her  pupils. 

Suggestions  for  a  sleep  survey  of  school  children 

1.  What  time  do  you  usually  go  to  bed? 

2.  How  many  times  per  week  do  you  go  to  bed  later  than 
this?  How  much  later? 

3.  How  long  does  it  usually  take  you  to  go  to  sleep? 

4.  At  what  hour  do  you  usually  wake? 

5.  How  many  times  a  week  do  you  sleep  later  than  this? 
How  much  later? 

6.  Does  some  one  wake  you  (call  you)  in  the  morning? 

7.  Do  you  ever  have  dreams  that  frighten  you?  How  of  ten? 
What  are  they  usually  about? 

8.  Are  you  afraid  to  sleep  in  a  room  alone? 

9.  How  many  other  persons  sleep  in  the  same  room  with 
you? 

10.  How  many  other  persons  sleep  in  the  same  bed  with  you? 

11.  How  many  windows  are  there  in  your  bedroom? 

12.  How  many  windows  did  you  have  open  last  night? 

13.  How  wide  were  they  open? 

14.  Do  you  sleep  in  an  ordinary  room,  or  out  of  doors,  or  or 
a  sleeping-porch? 

15.  Do  you  study  your  lessons  at  home?    What  lessons? 
What  time  in  the  day  or  night  do  you  do  home  study? 
How  many  minutes  or  hours  of  home  study  each  day? 

16.  Do  you  take  private  lessons  (that  is,  out  of  school)  in 
music,  painting,  etc.?  If  so,  how  much  time  does  this  take 
each  day? 

17.  Have  you  regular  work  to  do  outside  of  school,  such  as 


THE  SLEEP  OF  SCHOOL  CHILDREN       378 

selling  papers,  doing  chores,  helping  parents,  or  any- 
thing else  of  this  kind?  If  so,  how  much  time  does  it  take 
each  day? 

To  avoid  the  possible  effect  of  suggestion,  it  is  neces- 
sary to  give  the  questions  without  previous  discussion 
of  any  kind.  All  remarks  regarding  the  desirability  of 
bedroom  ventilation,  sufficient  sleep,  etc.,  should  be 
postponed  until  after  the  answers  have  been  secured. 
If  this  precaution  is  not  observed,  the  children  are 
likely  to  shape  their  answers  to  please  the  teacher, 
instead  of  giving  facts.  It  is  best  to  distribute  mimeo- 
graphed copies  of  the  questions  for  the  children  to 
answer  in  writing. 

REFERENCES 

(For  additional  references  on  sleep  the  reader  is  referred  to  the 
extensive  bibliographies  of  Manaceine  and  Sidis.) 
*1.  T.  D.  Acland:  On  Hours  of  Sleep  in  Public  Schools.  J.  and  A. 

Churchill,  London,  1905,  pp.  35. 

2.  J.  Mace  Andress:  "An  Investigation  of  the  Sleep  of  Normal 
School  Students."    Journal  of  Educational  Psychology,  March, 

1911,  pp.  153-56. 

*3.  Dr.  L.  Bernhard:  "Schlafzeit  der  Kinder."  Encyclopadie  der 
Modern  Kriminalistik,  vol.  11. 

*4.  E.  Claparede:  Experimental  Pedagogy  and  the  Psychology  of  the 
Child.  Longmans,  Green  &  Co.,  New  York,  1911,  pp.  306-17. 

*5.  E.  Claparede:  "Theorie  biologique  du  sommeil."     Arch,  de 

Psychologic,  vol.  iv,  1905,  pp.  245-349. 

6.  Clement  Duke:  Remedies  for  the  Needless  Injury  to  Children. 
London,  1899,  pp.  37. 

*7.  Leonard  G.  Guthrie:  Functional  Nervous  Disorders  in  Child- 
hood. Henry  Froude,  Hodder  &  Stoughton,  London,  1909, 
2ded. 

8.  H.  L.  Hollingsworth :  "Influence  of  Caffein  Alkaloid  on  the 
Quantity  and  Quality  of  Sleep."  Am.  Jour.  Psych.,  January, 

1912,  pp.  89-100. 

9.  E.  Jones:  "On  the  Nightmare."  American  Journal  of  Insanity, 
January,  1910. 

*10.  Marie  de  Manaceine:  Sleep;  Its  Physiology,  Pathology,  Hygiene, 
and  Psychology.  London,  1897,  pp.  341. 


380    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

11.  Michelson:  "Der  Schlaf  im  Kindesalter."  Psych.  Arbeiten. 
1899,  vol.  n. 

*12.  Caroline  Osborne:  "The  Sleep  of  Infancy  as  related  to  Physical 
and  Mental  Growth."  Pedagogical  Seminary,  March,  1912, 
pp.  1-47. 

*13.  Patrick  and  Gilbert:  "On  the  Effect  of  Loss  of  Sleep."  Psycho- 
logical Review,  vol.  in,  pp.  469-83. 

*14.  Alice  Ravenhill:  "Some  Results  of  an  Investigation  among 
Children  in  the  Elementary  Schools  of  England."  Internafl 
Mag.  Sch.  Hyg.  vol.  v,  1908,  pp.  9-28. 

15.  Alice  Ravenhill:  "Hours  of  Sleep  among  Elementary  School 
Children."   School  Hygiene,  July,  1910. 

16.  Dr.  Clive  Riviere:  "On  Sleep."  School  Hygiene,  1912,  pp.  109- 
18. 

17.  Dr.  R6mer:  "Ueber  einige  Beziehungen  zwischen  Schlaf  u. 
geistigen  Tatigkeiten."  Third  Internal.  Congress  for  Psychology. 
1896,  pp.  353  ff. 

18.  Boris  Sidis:  "Experimental  Study  of  Sleep."  Journal  of  Abnor- 
mal Psychology,  vol.  in,  pp.  1-32;  63-96;  170-99. 

*19.  Weygandt:  "Exper.  Beitrage  zur  Psychologic  des  Schlafes." 

Zeitschrift  f.  Psychologic,  1905,  pp.  1-41. 
20.  N.  Vaschide:  Le  Sommeil  et  les  Reves.     1911,  pp.  305.  (Has 

chapter  on  age  and  sex  differences.) 
*21.  Terman  and  Hocking:  "The  Sleep  of  School  Children."  Jour. 

Ed.  Psych.,  March.  April,  and  May,  1913. 


CHAPTER  XXI 

SOME  EVIL  EFFECTS  OF  SCHOOL  LIFE 

THE  school  is  a  formal  agency  devised  for  the  pur- 
pose of  bringing  the  child  into  possession  of  the  main 
body  of  our  social  inheritance,  —  the  treasures  of 
knowledge,  culture,  and  skill  laboriously  accumulated 
by  countless  generations  of  ancestors.  When  these 
treasures  were  few  and  pertained  mostly  to  the  affairs 
of  immediate  self-preservation,  there  was  little  danger 
of  overburdening  the  young  in  the  process  of  their 
acquisition.  To-day  the  case  is  different.  The  intri- 
cacy of  present-day  civilization  has  raised  mountains 
of  difficulties  which  must  be  met  and  overcome  by  all 
children  who  are  not  to  become  playthings  of  complex 
social  and  industrial  forces.  The  period  of  infancy  has 
not  lengthened  in  proportion  to  the  increased  educa- 
tional demands  upon  it.  The  school  term  has  been 
considerably  lengthened,  and  for  the  first  time  in  the 
world's  history  attendance  has  been  made  generally 
obligatory. 

That  this  situation  involves  certain  physical  dan- 
gers to  the  child  is  self-evident.  Indeed,  the  charge  of 
school  overpressure  has  been  made  repeatedly  for  at 
least  half  a  century.  The  complaints  have  come  chiefly 
from  physicians,  professors  of  pedagogy,  educational 
theorists,  and  parents;  only  occasionally  from  the  school 


382    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

itself.  Because  of  the  wide  variations  in  the  severity 
of  the  school's  demands  upon  its  pupils,  and  because  of 
the  individual  differences  in  the  ability  of  children  to 
meet  these  demands,  it  would  be  misleading  to  give  a 
categorical  answer  to  the  question  of  overpressure. 

Every  one  will  admit,  however,  that  injury  is  some- 
times inflicted  upon  the  child  by  the  activities  and 
environment  of  the  school.  Almost  every  chapter 
in  the  present  volume  has  presented  evidence  of  such 
injuries.  At  the  same  time,  the  school  is  usually  only 
one  of  several  factors  involved,  and  it  is  often  impossi- 
ble to  determine  with  certainty  the  exact  share  of  each 
in  the  production  of  the  ill  health  which  has  been 
found  so  prevalent  among  school  children  everywhere. 
That  the  school  is  one  of  the  important  causes  is  evi- 
denced by  the  results  of  many  investigations. 

The  school  as  a  cause  of  morbidity 

Hertel's  pioneer  study  (10)  of  the  health  conditions 
and  work  habits  of  3141  boys  and  1211  girls  in  the 
secondary  schools  of  Denmark  revealed  what  was  then 
regarded  an  incredible  amount  of  morbidity,  and 
demonstrated  sufficient  correlations  of  morbidity  with 
years  of  school  attendance  and  with  daily  hours  of 
study  forcibly  to  suggest  a  cause-and-effect  relation. 
In  the  first  two  classes  (children  8  to  10  years),  the 
percentage  of  morbidity  was  only  18.4;  that  is,  18.4 
per  cent  were  suffering  from  one  or  more  chronic 
defects  serious  enough  to  impair  health.  By  the  end 
of  the  third  year  the  amount  rose  to  34  per  cent,  and 


SOME  EVIL  EFFECTS  OF  SCHOOL  LIFE    383 


by  the  end  of  the  eighth  year,  with  its  average  of  8^ 
hours  of  daily  study,  to  nearly  50  per  cent.  The  pupils 
whose  studies  were  chiefly  of  a  scientific  nature  showed 
a  decidedly  lower  percentage  of  morbidity  than  that 
found  among  the  students  of  classical  courses.  This 
was  thought  to  be  due  to  the  heavier  demands  of  the 
classical  courses  upon  intellectual  application  and  to 
the  smaller  opportunity  afforded  for  physical  activity. 
Conditions  were  even  worse  among  the  girls,  among 
whom  morbidity  rose  from  about  30  per  cent  in  the 
first  two  grades  to  over  60  per  cent  by  the  age  of  12  to 
16  years.  The  sus-  ^ 
picion  is  justified 
that  the  daily  pe- 
riod of  study,  which 
increased  concomi- 
tantly  from  about 
seven  to  about  nine 
hours,  may  have 
been  causally  re- 
lated to  the  increase 
in  morbidity. 

The  later  study, 
made    by   Schmid- 
Monnard    (19), 
5100  boys  and  3200 
girls  in  the  second- 
ary schools  of  Ger- 
many, confirmed  essentially  all  the  findings  of  Hertel. 
The    above    figure    from    Schmid-Monnard    shows 


of** 


'7*3 

iV  «/ 


8       9      10      11     12     13     14 


FIG.  28 

Showing  increase  of  morbidity  with  age  among 
1900  girls  in  German  middle  schools.  (After 
Schmid-Monnard . ) 


384    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


the  rise  in  morbid- 
ity among  1900  girls 
in  a  middle  school 
and  the  correspond- 
ing increase  of  fre- 
quency for  head- 
aches, insomnia, 
and  outside  employ- 
ments. 

Figure  29  shows 
similar  correlations 
for  500  pupils  in  a 
girls'  higher  school. 
Roughly  speak- 
ing, schools  with 
both  morning  and 
afternoon  sessions 
showed  in  the  high- 
er grades  nearly 
twice  as  much  mor- 
bidity as  schools 
with  forenoon  sessions  only.  This  is  shown  in  the  fol- 
lowing table:  — 

TABLE   36 


FIG.  29 

Showing  increase  of  morbidity  with  age  among  500 
girls  in  a  German  secondary  school.  (After 
Schmid-Monnard . ) 


Morning  session  only 

Morning  and  afternoon 
sessions 

Average 

Maximum 

Average 

Maximum 

Total  morbidity 
Nervousness  and 
Headaches 
Insomnia 

25% 

13. 
1.5 

39% 

28 
5 

50% 

25 

4 

74% 

62 
19 

SOME  EVIL  EFFECTS  OF  SCHOOL  LIFE    385 

Both  Hertel  and  Schmid-Monnard  found  that  the 
percentage  of  morbidity  rises  considerably  toward  the 
end  of  the  school  year.  Mortality  also  slightly  in- 
creases for  a  brief  period  after  school  entrance;  like- 
wise the  incidence  of  infectious  diseases. 

The  American  study  of  high-school  pupils  by  John- 
son (14)  showed  that  those  pupils  who  were  not  well 
were  generally  the  ones  who  studied  most,  took  most 
private  instruction,  and  slept  least. 

The  most  extensive  and  important  single  investi- 
gation of  this  kind  yet  made  is  that  carried  out  by 
the  Russian  Department  of  Education,  the  results  of 
which  were  reported  by  Khlopine  in  1911  (13).  This 
investigation  was  essentially  a  health  census  of  all  the 
secondary  schools  of  the  Russian  Empire,  carefully 
and  uniformly  carried  out  under  the  direction  of  the 
Chief  Medical  Officer  of  Schools.  The  census  was  taken 
in  1905-06,  and  included  about  116,000  out  of  the 
139,000  pupils  enrolled  in  the  secondary  schools.  Its 
main  purpose  was  to  establish  the  incidence  for  age, 
grade,  sex,  and  type  of  school  of  the  following  defects: 
myopia,  spinal  curvature,  nasal  hemorrhages,  head- 
aches, and  nervous  troubles. 

The  following  chart,  which  has  been  constructed 
from  the  numerous  tables  given  by  Khlopine,  presents 
a  summary  of  his  results  in  so  far  as  they  throw  light 
upon  the  correlation  between  physical  defectiveness 
and  the  length  of  school  attendance. 

Khlopine's  data  show  that  the  frequency  of  myopia 
varies  only  very  slightly  according  to  sex;  that  it 


386    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


increases  gradually  from  eastern  to  western  Russia 
and  from  smaller  to  larger  cities;  and  that  it  is  higher 

in  the  technical 
than  in  the  classical 
or  modern-language 
schools.1 

Nasal  hemor- 
rhage is  caused  in 
part  by  the  conges- 
tion of  blood  about 
the  head  resulting 
from  the  forward 


22.5 

20. 

17.5 

15. 

12.5 

10. 

7.5 

5. 

2.5 


nef vou 


s__£ 


Grii<!._- 


inclination    of    the 

ii  in  iv  v   vi  vn  vni    body  in  reading  and 
FIG.  so  from    the   intellec- 

Showing    percentage  of    certain  defects  according  i          j  ,•          i 

to  grade  for  pupils  in  the  secondary  schools  of     tual  and   emotional 
Russia.  This  chart  summarizes  one  of  the  most 

important    investigations   of    this    type.     (After     tension      of      School 
Khlopine'a  tables.) 

life.  Nasal  hemor- 
rhage is  not  ordinarily  a  summation  effect  from  long- 
continued  unwholesome  conditions.  If  it  does  not 
appear  in  the  lower  grades  it  is  not  likely  to  appear 
at  all.  This  tends  to  conceal  its  dependence  upon 
school  life:  but  that  this  dependence  is  none  the  less 
real  seems  to  be  demonstrated  by  the  following  table 
from  Khlopine  showing  the  relative  infrequency  of 
nose-bleed  in  the  technical  schools :  — 

1  The  influence  of  the  school  in  the  production  of  myopia  is  now 
known  to  be  much  less  than  it  was  formerly  believed  to  be.  It  is  one 
Victor,  but  not  the  leading  one.  See  chapter  xiv. 


SOME  EVIL  EFFECTS  OF  SCHOOL  LIFE    387 

TABLE  37 

Type  of  School  Frequency  of  nasal 

hemorrhage 

T>       ,  f  Classical  schools  3.2  per  cent 

(  Modern-language  schools  2.7 

Girls'  schools  3.1 

Technical  schools  1.7 

This  difference  in  favor  of  the  technical  schools 
exists  in  spite  of  their  excessively  heavy  program,  and 
may  be  due  to  the  greater  amount  of  physical  activity 
which  they  permit  as  compared  with  other  schools. 

For  spinal  curvature,  the  figures  given  show  an 
increase  of  only  about  50  per  cent  from  the  first  to  the 
sixth  grade,  but  it  is  by  no  means  clear  that  this  tells 
the  whole  story.  It  is  possible  that  but  for  the  unhygi- 
enic postures  assumed  by  the  school  child  the  incidence 
of  spinal  curvature  would  show  a  fall  at  the  close  of  the 
period  of  accelerated  adolescent  growth. 

Headaches  double  in  frequency  from  the  first  to 
the  seventh  grade;  (other)  nervous  troubles  increase 
nearly  fivefold.  The  significance  of  these  and  related 
symptoms  has  been  set  forth  at  some  length  in  chap- 
ters xv  to  XVHI.  Khlopine  seems  well  justified  in  con- 
cluding that  the  school  must  be  conducted  in  strict 
accordance  with  the  best  standards  of  school  hygiene, 
and  that  its  medical  service  must  be  improved,  if  it 
would  avoid  the  danger  of  injuring  the  health  of  it- 
pupils. 

That  we  are  not  able  to  marshal  as  convincing  an 
array  of  incriminating  evidence  against  the  schools  of 
our  own  country  is  due  more  to  the  lack  of  data  than 


S88    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


to  the  absence  of  school  injury.  As  far  as  evidence  is 
available,  it  points  to  conditions  of  morbidity  not 
greatly  different  from  those  existing  in  the  schools  of 
Russia,  Germany,  Denmark,  and  Sweden. 

The  effects  of  school  life  upon  growth 

Schmid-Monnard  sought  to  ascertain  the  influence 
of  school  life  on  the  body  by  comparing  the  growth 
attained  during  the  seventh  year  of  life  by  children  in 
the  school  with  that  attained  in  the  same  year  by  chil- 
dren who  had  not  entered  school.  The  results,  as 
shown  in  Table  38,  indicate  that  school  entrance  brings 
a  shock  to  the  nervous  system  of  the  young  child 
severe  enough  to  retard  growth. 

TABLE  88 


Growth  iu  weight  — 
expressed  in  kg. 

Growth  in  height  — 
expressed  in  cm. 

Boys 

Girl* 

Boys 

Girls 

Pupils  not  attending  school 
Pupils  attending            " 
Difference  in  favor  of  former 

2.2 
1.5 
.7 

1.9 
1.6 
.3 

7.4 
4.2 
8.2 

5.6 
4.5 
1.1 

Engelsperger  and  Ziegler  (7)  weighed  about  500 
children,  5  to  6  years  of  age,  on  entering  school,  and 
again  two  months  later,  and  found  that  20  per  cent 
had  lost  weight.  This  loss  occurred  at  just  that  season 
of  the  year  when  growth  in  weight  is  normally  most 
rapid.  All  should  have  gained.  The  retarding  effect 
was  most  marked  in  the  youngest  pupils,  those  under 
6  years  of  age.  The  authors  conclude  that  entrance 


SOME  EVIL  EFFECTS  OF  SCHOOL  LIFE    389 

before  6  years  should  never  be  permitted  and  that 
many  pupils  ought  not  to  enter  school  before  the  age 
of  7  or  8.  Quirsfeld  (18)  followed  the  growth  of  1014 
children  through  the  first  four  years  of  school  life  and 
found  that  46  per  cent  failed  to  gain  weight  during  the 
entire  first  school  year,  while  21  per  cent  showed  an 
actual  loss.  The  number  failing  to  gam  during  the 
second  year  was  only  10  per  cent,  the  third  year  8  per 
cent,  and  the  fourth  year  about  6  per  cent. 

Wretlind's  measurements  of  3647  children,  aged  7 
to  17,  showed  that  the  average  gain  in  height  for  the 
three  months  of  summer  vacation  ranged  from  30  to 
80  per  cent  as  great  as  that  for  the  entire  nine  months 
of  the  school  year.1  Whether  seasonal  influences  alone 
were  responsible  for  this  difference,  or  whether  a  part 
of  it  was  due  to  the  cessation  of  the  school,  we  do  not 
know. 

Binet  in  France  and  Schuyten  in  Belgium  sought  to 
determine  the  effect  of  school  life  on  the  child  by  ascer- 
taining the  changes  in  appetite  during  the  school  year. 
The  quantity  of  bread  consumed  in  the  daily  school 
meal  was  used  as  a  general  index  of  appetite.  On  the 
basis  of  exact  records  showing  the  amount  consumed 
each  day  for  a  school  year,  both  investigators  state 
that  the  consumption  of  bread  diminishes  during  the 
course  of  the  year,  and  conclude  that  intense  intel- 
lectual work  injures  the  appetite. 

In  another  study,  Schuyten  has  attempted  to  ascer- 
tain by  a  more  direct  method  the  effect  of  the  school 
1  Quoted  in  reference  17  to  chapter  in,  this  book. 


390    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

upon  the  child's  state  of  nutrition  (22).  By  use  of 
the  Oppenheimer  formula  for  determining  nutrition,1 
Schuyten  made  a  study  of  1100  boys,  3  to  14  years  of 
age,  and  300  girls,  3  to  6  years  of  age,  for  the  purpose 
of  finding  any  relation  that  might  exist  between  the 
state  of  nutrition  and  the  length  of  school  attendance. 
For  statistical  purposes  the  pupils  were  grouped  ac- 
cording to  age  by  half-years,  50  in  each  half-year. 

The  results  are  stated  as  follows:  "The  nutrition 
coefficient  of  girls  attending  the  kindergarten  drops 
from  the  third  to  the  sixth  year.2  That  of  the  boys 
drops  throughout  the  classes  from  the  third  to  the 
eighth  year,  rising  again  somewhat  up  to  ten  years, 
and  remaining  constant  at  this  lower  value  up  to  four- 
teen. .  .  .  The  condition  of  nutrition  found  at  the 
onset,  which  is  excellent,  does  not  return."  After 
losing  severely  in  energy  of  nutrition  and  assimilation 
up  to  the  eighth  year,  it  appears  that  the  child's  body 
partially  adapts  itself  to  the  new  regime.  Up  to  the 
fourteenth  year,  however,  there  is  inability  to  reach 
their  original  excellent  condition. 

Effects  upon  the  appetite,  nutrition,  and  the  composition 
of  the  blood 

One  of  the  evils  most  often  blamed  for  school  over- 
pressure is  the  formal  examination.  In  1896,  Serafani 
discovered  that  examinations  caused  a  marked  reduc- 


1  Girth  of  arms  X  100 

-^r— • — TTT —  nutrition  coefficient. 

Chest  girth 

1  Girls  older  than  6  were  not  examined. 


SOME  EVIL  EFFECTS  OF  SCHOOL  LIFE    391 

tion  in  the  amount  of  nourishment  taken  by  university 
students,  and  a  corresponding  decrease  of  weight.  His 
conclusion  was  to  the  effect  that  prolonged  examina- 
tions tend  to  bring  about  a  condition  of  the  nervous 
system  strongly  resembling  that  of  neurasthenic  per- 
sons. 

Ignatieff  (11)  made  a  study  of  the  physical  effects  of 
examinations  on  242  pupils,  10  to  16  years  of  age,  in  a 
Moscow  military  school.  The  pupils  were  weighed  just 
before  they  began  preparation  for  the  examinations, 
again  at  the  close  of  the  examinations,  and  finally  after 
the  close  of  the  ensuing  3|  months  of  vacation.  Com- 
paring the  second  weighing  with  the  first,  we  find  that 
79  per  cent  had  lost  weight,  about  11  per  cent  had  not 
changed,  and  only  10  per  cent  had  made  any  gain. 
Since  the  examination  and  the  preparation  for  it 
extended  over  a  period  of  from  one  to  two  months, 
and  since  the  pupils  were  at  an  age  where  growth  from 
month  to  month  is  normally  very  rapid,  all  should 
have  gained.  As  it  was,  those  of  the  lowest  grade  lost 
on  an  average  2  per  cent  of  their  weight;  those  of  the 
highest  classes  over  3  per  cent.  Quite  different  is  the 
result  when  we  compare  the  third  weighing  (after 
vacation)  with  the  second  (before  vacation),  for  here 
we  find  loss  of  weight  with  only  4.6  per  cent  and  gain 
with  90  per  cent.  For  13  pupils,  the  extended  vacation 
was  not  sufficient  to  make  up  the  loss  of  weight  suf- 
fered during  the  strenuous  pre-vacation  period.  Igna- 
tieff concludes  that  in  its  physical  effects,  the  extended 
examination  is  comparable  to  a  severe  illness,  and  that 


392    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

a  mental  strain  severe  enough  to  cause  such  marked 
alterations  in  metabolism  could  hardly  fail  to  affect 
unfavorably  that  organ  most  concerned  in  the  over- 
pressure, —  the  brain  itself. 

Koginoff,  in  a  similar  experiment,  found  a  loss  in 
weight  among  75  per  cent  of  the  pupils  concerned. 
He  states  that  the  remaining  25  per  cent  who  were  not 
so  unfavorably  affected  were  either  lazy  or  of  optimistic 
temperament. 

This  point  deserves  emphasis.  The  child  of  nervous 
temperament,  who  worries  easily,  is  extremely  liable 
to  suffer  from  overpressure.  Worry  acts  both  as  cause 
and  effect,  and  fosters  a  vicious  circle  of  influences. 

Data  of  this  kind  lead  us  to  infer  that  the  intensive 
nervous  stimulation  involved  in  excessive  mental  work 
produces  its  injury  through  its  reflex  effects  upon  the 
nutritional  processes  and  upon  sleep.  Graziani,  how- 
ever, has  raised  the  question  whether  there  may  not 
be  unfavorable  influences  more  direct  than  that  in- 
volved in  this  explanation.  These  he  believes  are  of 
two  possible  kinds:  (1)  Imperfect  oxygenation  of  the 
blood  and  incomplete  elimination  of  carbon  dioxide 
due  to  the  superficial  respiration  which  has  been  proved 
by  Mosso,  Macdonald,  Bush,  Obici,  and  others  to 
result  from  application  to  mental  tasks;  and  (2)  an 
immediate  effect  upon  the  chemical  composition  of  the 
blood  corpuscles  due  to  the  accumulation  of  fatigue 
toxins  resulting  from  mental  work. 

In  order  to  test  the  latter  theory,  Graziani  subjected 
18  university  students  and  17  children  of  10  to  12 


years  of  age  to  blood  tests  before  and  after  the  prepar- 
atory period  for  school  examinations.  The  tests  in- 
volved three  determinations:  the  number  of  red  cor- 
puscles, the  relative  proportion  of  haemoglobin  which 
they  contained,  and  their  power  of  resistance.  In 
regard  to  the  number  of  corpuscles,  no  constant  differ- 
ences were  found  either  with  university  students  or 
children.  The  proportion  of  haemoglobin,  however, 
showed  a  decided  decrease,  amounting  to  10  per  cent 
with  the  students,  and  to  7.4  per  cent  with  the  chil- 
dren. The  effect  upon  the  power  of  resistance  of  the 
red  corpuscles  was  much  the  same  as  other  investi- 
gators had  shown  to  result  from  weak  poisons. 
Graziani,  therefore,  concludes  that  intellectual  work 
probably  produces  a  toxin  which  brings  about  an 
immediate  change  in  the  chemical  and  functional 
properties  of  the  blood. 

To  try  this  theory  still  further,  Graziani  subjected 
himself  and  a  12-year-old  boy  to  the  same  kind  of 
blood  examinations,  except  that  in  this  experiment  the 
blood  tests  were  separated  only  by  a  number  of  hours 
of  strenuous  mental  work  instead  of  many  weeks,  as 
was  the  case  in  the  earlier  experiment.  Here,  again, 
the  decrease  of  haemoglobin  was  marked,  amounting 
to  7.5  per  cent  with  Graziani  himself  and  to  8  per  cent 
with  the  boy.  The  experimenter  concludes  that  the 
underlying  cause  of  school  anaemia,  with  its  altera- 
tions of  metabolism  and  its  imperfect  oxygenation  of 
the  blood,  is  to  be  sought  in  the  influence  of  excessive 
accumulations  of  toxic  products  of  fatigue. 


394    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

Another  important  study  of  the  same  type,  made  by 
Dr.  Helwig  (9),  entirely  corroborates  the  findings  of 
Graziani.  This  author  made  many  blood  tests  upon 
himself  and  six  other  subjects  for  the  purpose  of  deter- 
mining the  influence  of  school  work,  fresh  air,  rest, 
marches,  and  lessons  of  different  degrees  of  difficulty, 
both  upon  the  number  of  red  corpuscles  and  upon  their 
"degenerative"  and  "regenerative"  processes.  The 
study  seems  to  have  been  made  with  the  most  approved 
technique  and  with  due  regard  for  scientific  accuracy. 

The  results  were  rather  variable  for  the  corpuscle 
count,  but  for  the  "  degenerative  "  and  "  regenerative  " 
processes  they  were  strikingly  uniform. 

As  a  result  of  school  work,  the  "disintegration 
quotient"  was  increased  29  out  of  33  times.  The 
author  holds  that  the  study  "distinctly"  demonstrates 
that  school  work  not  only  imposes  a  strain  upon  the 
nervous  system ,  but  that  it  also  produces  a  destructive 
effect  on  the  blood  corpuscles.  The  numerous  tables 
presented  by  the  author  show  the  influence  of  the  fol- 
lowing factors  upon  the  condition  of  the  blood:  the 
difficulty  of  the  school  work,  the  length  of  the  work 
period,  the  frequency  of  the  recitation  intervals,  the 
amount  of  exercise,  and  the  access  to  fresh  air. 

Helwig  concludes  that  "arduous  mental  work  pro- 
duces unfavorable  changes  in  the  blood;  that  recuper- 
ation is  marked  by  the  elimination  of  waste  products 
and  by  a  more  or  less  active  regeneration  of  cor- 
puscles." Observation  of  the  children  showed  that 
"'external  manifestations  of  fatigue  invariably  accom- 


SOME  EVIL  EFFECTS  OF  SCHOOL  LIFE    395 

pany  the  microscopical  phenomena  associated  with 
this  state." 

It  was  not  only  from  highly  sensitive  children  that 
reactions  were  obtained.  The  author  observed  the 
same  phenomena  in  his  own  person  after  long-con- 
tinued mental  strain.  "While  a  considerable  degree 
of  corpuscle  disintegration  could  be  noted  in  the  morn- 
ing after  several  weeks  of  concentrated  sedentary  work 
indoors,  accompanied  by  physical  depression,  lassitude, 
and  heaviness,  this  phenomenon  disappeared,  together 
with  the  subjective  symptoms,  after  a  walk  of  two 
hours.  On  another  occasion,  the  disintegration  quo- 
tient increased  considerably  after  four  hours'  inces- 
sant work  at  the  microscope  prior  to  taking  food  and 
following  a  prolonged  period  of  close  application  to 
research  work,  but  decreased  rapidly  after  two  hours* 
devotion  to  a  totally  different  occupation  and  after 
lunch  taken  in  the  open  air."  Rest  days  showed  an 
immediate  effect  on  the  disintegration  quotient.  Long 
and  tiring  marches  produced  only  small  degenerative 
values  and  were  followed  by  rapid  regeneration. 
During  a  day  of  mental  work  disintegration  continu- 
ally increased  until  late  in  the  afternoon,  indicating 
that  this  part  of  the  day  is  least  suitable  for  hard 
study. 

The  reverse  phenomenon,  the  improvement  which 
takes  place  in  the  composition  of  the  blood  as  the  result 
of  a  well-spent  summer  vacation,  has  been  dealt  with 
experimentally  by  Borchmann  (4),  who  gave  blood 
tests  to  19  boys  and  18  girls  of  Moscow  before  a  two 


396    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


months'  "summer  colony"  outing  and  again  after 
their  return.  The  second  test  revealed  an  average 
gain  of  nearly  a  million  red  corpuscles  per  cubic  milli- 
meter of  blood  and  a  marked  increase  of  haemoglobin. 
This  is  shown  hi  the  following  table:  — 

TABLE  39 


Boys 

Girls 

Red  corpuscles 
per  cubic  mm. 

Percentage  of 
hemoglobin 

Red  corpus- 
cles     per 
cubic  mm. 

Percentage  of 

btenioglobin 

Before  vacation 
After  vacation 

3,884,000 
4,8£0,000 

73.1 

79.2 

3,760,000 
4,480,000 

69.6 
78.3 

Borchmann  also  tested  eight  of  the  girls  two  months 
after  their  return  to  school,  and  found  that  in  three  the 
number  of  red  corpuscles  had  still  further  increased 
about  a  quarter-million  per  cubic  millimeter,  while  in 
the  other  five  there  was  a  decrease  of  about  two  thirds 
of  a  million  as  compared  with  the  second  count.  But 
in  no  case  was  the  condition  as  unfavorable  as  before 
the  vacation.  The  haemoglobin  had  in  some  cases 
decreased  5  per  cent  below  the  second  showing;  in 
others  had  increased;  but  in  all  cases  it  surpassed  the 
pre- vacation  record.  Leuch  had  already  secured  sim- 
ilar results  for  children  of  Geneva,  and  the  work  of 
both  is  strikingly  corroborated-  by  blood  tests  of  chil- 
dren who  have  been  transferred  from  unhygienic 
conditions  of  the  ordinary  classroom  to  the  open-air 
school.1 

1  See  chapter  on  open-air  schools  in  Health  Work  in  the  Schools, 
by  Hoag  and  Terman.  Houghton  Mifflin  Co. 


SOME  EVIL  EFFECTS  OF  SCHOOL  LIFE    397 

The  effects  of  school  postures  on  respiration 
The  effects  of  school  occupations  on  the  respiration 
have  been  studied  experimentally  by  Oker-Blom  (17) 
and  by  Badaloni  (2).  The  latter  secured  kymographic 
records  showing  variations  in  the  depth  of  respiration 
in  the  upper  part  of  the  lungs  resulting  from  different 
postures  assumed  in  writing.  It  was  found  that  the 
asymmetrical  position  induced  an  inflexibility  of  the 
upper  part  of  the  chest  and  caused  decreased  depth 
of  respiration  in  the  upper  part  of  the  lowered  side. 
Later,  Binet  raised  the  question  whether  this  may  not 
be  compensated  by  simultaneously  increased  abdom- 
inal breathing.  In  a  second  study,  Badaloni  was  able 
to  prove  that  no  such  compensation  takes  place.  His 
records  show  that  the  asymmetrical  position  brings  a 
"remarkable  decrease"  in  the  expanding  capacity  of 
the  upper  chest.  The  symmetrical  sitting  posture, 
even  when  the  sternum  was  allowed  to  touch  the  desk, 
showed  a  less  injurious  effect.  The  author  concludes 
that  the  asymmetrical  position,  even  more  than  the 
sitting  posture,  per  se,  is  responsible  for  the  school's 
evil  effects  upon  the  lungs.  He  believes  that  the 
school  is  hi  this  way  an  important  cause  of  tubercu- 
losis. 

In  1911,  Oker-Blom  (17)  reports  a  similar  experi- 
mental study  of  respiration,  carried  on  with  25  pupils 
during  different  school  occupations.  The  most  marked 
difference  found  was  that  between  standing  and  sitting. 
The  decrease  in  total  respiration  for  brief  sitting  (3 
minutes)  was  about  8  per  cent,  and  for  longer  periods 


398    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

(12  to  39  minutes),  50  per  cent.  Interesting  differences 
appeared  with  different  kinds  of  school  work.  Knit- 
ting, for  example,  showed  an  impeding  effect  upon  the 
respiration  of  the  upper  left  lung  18  per  cent  greater 
than  did  reading  aloud.  In  agreement  with  the  results 
of  Badaloni,  the  greatest  impediment  to  respiration 
was  found  in  the  upper  part  of  the  lowered  side  of  the 
chest.  This,  in  turn,  increases  the  asymmetrical  condi- 
tion and  helps  to  explain  why  scoliosis  sometimes  runs 
a  progressive  course.  Oker-Blom  concludes  that  all 
kmds  of  school  activities,  including  hand-work,  should 
be  frequently  alternated  with  change  of  position  and 
with  physical  exercises. 

Psycho-pathological  effects  of  school  life 

There  is  reason  to  believe  that  the  intellectual 
apathy  of  older  children  and  adults  is  sometimes  due 
to  school  over-dosage  or  to  other  kinds  of  educational 
malpractice.  It  has  often  been  charged  that  the  school 
has  a  depressing  effect  upon  the  child's  spontaneity; 
that  it  mechanizes  his  mental  processes,  and  destroys 
the  individualistic  elements  of  his  personality. 

The  depressing  and  inhibitory  effects  of  school  upon 
the  child's  mind  are  of  such  a  nature  that  their  ob- 
jective measurement  is  of  course  very  difficult.  An 
attempt  at  such  measurement  has  been  made,  however, 
by  the  Belgian  psychologist,  Schuyten.  The  investiga- 
tion in  questio'n  was  undertaken  on  the  assumption 
that  the  supposed  unfavorable  influence  of  the  school 
would  probably  be  revealed  in  the  character  of  the  child's 


SOME  EVIL  EFFECTS  OF  SCHOOL  LIFE    399 


spontaneously  controlled  drawings.  Accordingly,  200 
children  of  each  age  (100  boys  and  100  girls),  from 
3  to  13  years,  were  asked  to  make  a  "drawing  of  a 
boy."  The  direction  was  given  orally  and  without 
explanation  or  suggestion,  everything  being  left  to  the 


Age      3 


10 


11      12       13 


MM 
90 

80 
70 
60 
50 
40 
80 
20 
10 


FIG.  31 

The  effect  of  school  entrance  on  the  size  of  children's  spontaneously  controlled 
drawings.    (After  Schuyten.) 

spontaneity  of  the  child.  The  blank  sheets  of  paper 
and  pencils  supplied  were  of  uniform  size  and  material. 
The  drawings  thus  secured  were  measured  in  length  and 
width  for  the  purpose  of  ascertaining  age  differences. 
The  results  are  embodied  in  the  accompanying  figure. 
It  is  seen  that  the  child's  entrance  into  the  school 


400    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

brings  an  almost  immediate  decrease  in  the  size  of  his 
spontaneous  drawings;  that  the  pre-school  norm  for 
width  of  drawing  is  not  again  reached  by  either  boys 
or  girls,  and  that  the  pre-school  norm  for  height  is 
reached  only  after  two  and  a  half  years.  Schuyten 
claims  to  have  found  also  a  corresponding  deterio- 
ration in  the  quality  of  the  drawings  as  judged  by 
aesthetic  standards. 

The  explanation,  in  the  opinion  of  Schuyten,  is  as 
follows.  The  child  in  the  kindergarten  is  free,  active, 
and  unburdened  by  care.  At  six  he  is  precipitated  into 
the  routine  and  serious  work  of  the  school  entirely 
without  transition  or  preparation.  Here  not  only  is 
play  prohibited,  but  almost  every  kind  and  degree  of 
physical  activity  as  well.  He  is  governed  by  unreason- 
ing notions  of  severity.  Not  being  permitted  to  see, 
hear,  speak,  or  move,  except  within  certain  narrow 
and  arbitrary  limits,  his  "dilatation"  ceases,  his  per- 
sonality undergoes  a  general  recoil,  and  the  dynamo- 
genie  effects  of  gayety  are  lost  (21).  In  some  cases  the 
fear  "complex"  develops. 

Whatever  we  may  think  of  the  validity  of  Schuy- 
ten's  simple  experiments,  the  fact  that  the  school  does 
not  always  develop  self-reliance  and  the  power  of  inde- 
pendent thinking  is  conceded  by  every  one.  How  to 
carry  on  the  routine  work  of  the  school  without  dead- 
ening the  native  intellectual  interests  and  curbing 
overmuch  the  child's  personality  is  a  problem  whose 
solution  must  be  sought  anew  by  every  generation  of 
teachers. 


SOME  EVIL  EFFECTS  OF  SCHOOL  LIFE    401 


The  annual  accumulation  of  fatigue 
Several  investigations  indicate  that  mental  fatigue 
accumulates  during  the  school  year.     Schuyten,  for 
example,  conducted  for  an  entire  school  year  a  series 
of  fatigue  tests  by  means  of  the  esthesiometer  upon 
11  boys  and  10  girls.  M  M 
The  tests  were  given 
daily  during  the  first 
week  of  each  school 
month  and  the  re- 
sults for  the  differ- 
ent   months     were 
then     compared. 
Preliminary  tests  to 
accustom  the  chil- 
dren to  the  experi- 
ment had  been  given 
for  two  months  at 
the  close  of  the  pre- 
vious  school  year. 
The  accompanying 
curves  show  the  average  month  by  month  decrease  hi 
sensitivity  of  the  skin  of  boys  and  girls  for  the  second 
year. 

In  another  series  of  experiments  Schuyten  gathered 
important  evidence  of  the  deterioration  which  the 
voluntary  attention  of  children  undergoes  under  vari- 
ous influences.  His  attention  test,  which  consisted  of 
a  five-minute  reading  lesson,  was  given  four  times  daily 
(at  8  and  11  o'clock  hi  the  morning  and  at  2  and  4  in 


ao 

19 
18 
17 
16 
15 
14 

13 
12 
11 
ID 

&r'' 

-"\ 

/ 

o/1 

*** 

-~/ 

,' 

r 

r~ 

-\ 

r 

/ 
/ 

$ 

/ 

V 

/ 
r 

7 

f 

/ 

A 

/ 

/ 

/ 

/ 

123456789    10 

Month  of  School  Year 

FIG.  32 

The  annual  curre  of  fatigue  in  school  children  u 
measured  by  the  esthesiometer.  Greater  ver- 
tical distance  means  decreased  sensitivity  of  the 
skin.  The  two  vertical  dotted  lines  represent 
brief  vacations.  Note  their  effect  on  curves. 
(After  Schuyten.) 


402    THE  HYGIENE  OF  THE  SCHOOL  CHILD 


the  afternoon),  for  an  entire  school  year  to  the  pupils 
of  16  classes.  Besides  demonstrating  a  decline  of 
attention  from  8  to  11  in  the  forenoon  and  from  2  to  4 
in  the  afternoon,  the  results,  as  graphically  represented 
in  the  following  curve,  demonstrate  an  astonishing 
decline  in  the  power  of  attention  toward  the  end  of  the 
school  year. 

A  part  of  this  decrease  in  the  power  of  voluntary 
effort  may,  of  course,  be  due  to  the  influence  of  the 

higher  tempera- 
ture of  the  spring 
and  summer 
months.  This  is 
indicated  by  the 
upward  slope  of 
the  curve  during 
the  autumn.  At 
the  same  time,  in 
the  light  of  sup- 
plementary evi- 
dence from  other  fatigue  studies,  it  would  be  unreason- 
able to  explain  the  curve  entirely  on  the  temperature 
theory.  Lobsien,  in  a  lengthy  series  of  memory  tests, 
has  found  a  similar  decline  in  the  memory  ability 
of  children  during  the  school  year. 

It  is  well  to  emphasize  that  inattention  is  more  than 
a  mere  index  of  mental  efficiency.  Its  function  is  also 
a  positive  one;  it  is  a  protective  agency,  designed  to 
conserve  the  deeper  levels  of  energy  from  too  complete 
exhaustion.  It  is  a  beautiful  and  necessary  adaptation 


GU 
55 
50 
45 
40 
35 

Oct.  Nov.  Dec.  Jan.  Fj 

b.Mch.  Apr.May  June  Ji 

j 

/ 

\ 

/ 

\ 

/ 

\ 

\ 

\ 

FIG.  33 

Showing  curve  of  mental  fatigue  during  the  school 
year  as  measured  by  Schuyten's  attention  test. 
Vertical  distance  represents  the  percentage  of  chil- 
dren, whose  attention  did  not  fail  during  the  test. 


SOME  EVIL  EFFECTS  OF  SCHOOL  LIFE    403 

of  nature  that  the  psychophysical  organism  accumu- 
lates stores  of  energy  which  it  refuses  to  draw  upon 
except  under  the  greatest  provocation  and  at  moments 
of  unusual  stress.  This  is  the  factor  of  safety,  which  it 
is  the  function  of  sleep,  inattention,  and  other  rest 
states  to  conserve.  Inattention  is,  therefore,  an  indis- 
pensable factor  in  mental  economy  —  not  a  moral 
fault,  but  a  safety-valve.  Teachers  should  learn  to 
respect  it.1  Kraepelin  has  even  suggested  that  "poor 
teachers  are  a  hygienic  necessity";  that  highly  inter- 
esting instruction  continued  for  six  or  seven  hours 
a  day  would  inevitably  bring  about  a  condition 
of  fatigue  in  excess  of  the  limits  of  safety. 

Disturbance  of  the  motor  functions  is  one  of  the 
common  symptoms  of  nervous  exhaustion.  Toward 
the  end  of  the  school  year  automatisms  increase  in 
number,  the  liability  to  chorea  increases,  postures 
become  more  faulty,  loss  of  tone  in  the  ciliary  muscle 
makes  "latent"  hyperopia  or  "latent"  astigmatism 
"manifest."  The  loss  of  muscular  tone  is  especially 
evident  in  the  aggravation  of  speech  defects.  (See 
chapter  xx.) 

Without  doubt,  the  evil  effects  of  school  life  would 
be  more  often  observable  were  it  not  for  the  plasticity 
of  growth  which  enables  children,  like  the  guinea  pigs 
in  the  experiment  of  Professor  Minot,  to  repair  many 
kinds  of  physical  damage.  Nevertheless,  in  spite  of 

1  In  Triplett's  study  of  The  Faults  of  Children,  "inattention" 
headed  the  list  in  the  frequency  with  which  it  was  named  by  teachers 
as  the  "greatest  fault  of  children." 


404    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

the  child's  wonderful  power  of  rebound,  we  have  found 
unmistakable  evidence  of  the  injurious  effects  of  the 
school.  The  close  correlation  of  morbidity  with  years  of 
school  attendance,  with  length  of  daily  program,  and  with 
the  progression  of  the  school  term  ;  the  deterioration  of  at- 
tention toward  the  end  of  the  school  year ;  the  damaging 
effects  of  strenuous  school  activities  upon  appetite,  diges- 
tion, metabolism,  and  the  constitution  of  the  blood  ;  the  ill 
effects  of  deprivation  from  fresh  air  and  from  healthful 
physical  exercise;  the  impairment  of  nervous  coordina- 
tions and  the  profound  disturbances  reflexly  produced  by 
worry  —  these  and  other  injurious  effects  have  been  suffi- 
ciently attested  to  justify  the  most  vigorous  prosecution  of 
reform  in  matters  of  educational  hygiene. 

Some  of  the  worst  consequences  are  either  deferred, 
or  else  are  of  such  intangible  character  that  they  are 
not  apparent  to  common  observation.  In  the  former 
class  belong  the  sedentary  habits  instilled  by  the  many 
years  of  school  life.  These  remain  with  most  of  us  as 
an  unclosed  debit  account,  exacting  throughout  life  a 
progressively  usurious  toll  of  health  and  happiness. 

It  is  not  claimed,  of  course,  that  school  life  is  detri- 
mental to  the  health  of  all  children.  Fortunately  the 
exuberance  of  vitality  is  so  marked  a  characteristic  of 
childhood  and  youth  that  many  escape  without  having 
suffered  observable  injury.  It  is  the  child  of  somewhat 
less  than  normal  resistance  who  breaks  under  the 
pressure. 

Nor  are  the  evils  which  do  exist  beyond  remedy. 
There  is  no  reason  why  the  school  should  not  be  as 


SOME  EVIL  EFFECTS  OF  SCHOOL  LIFE    405 

healthful  in  its  influence  upon  both  body  and  mind  as 
the  most  perfectly  ordered  home.  Until  it  approxi- 
mates this  ideal,  the  campaign  for  school  reform  should 
continue. 

By  proper  attention  to  schoolhouse  construction, 
and  to  heating,  lighting,  ventilation,  and  sanitation; 
by  the  multiplication  of  open-air  schools;  by  a  thor- 
ough and  universal  system  of  medical  supervision;  by 
reducing  seat  work  to  a  minimum  so  as  to  give  more 
time  for  manual  activities  and  play;  by  completely 
eliminating  home  study  below  the  high  school  and  by 
rigidly  limiting  it  to  one  or  two  hours  thereafter;  by 
observing  the  laws  of  fatigue  in  the  school  day;  by  the 
substitution  of  freedom  for  the  atmosphere  of  repres- 
sion; by  making  the  cultivation  of  physical  and  mental 
health  as  much  its  aim  as  the  imparting  of  knowledge, 
the  school  can  avoid  all  the  injuries  we  have  men- 
tioned, and  others.  Until  all  of  these  reforms  have 
become  general,  the  school  will  continue  to  mingle 
evil  with  the  good  it  accomplishes. 

Types  of  children  who  are  sometimes  injured  by  the  work  or 
environment  of  the  school 

1.  Children  who  are  poorly  fed. 

2.  Anaemic  children. 

3.  Those  with  chronic  indigestion. 

4.  Children  with  tendency  to  constipation. 

5.  Children  with  tubercular  tendencies. 

6.  Children  with  obstructed  nasal  breathing. 

7.  Children  whose  muscular  development  is  weak. 

8.  Children  whose  vision  is  defective. 


406    THE  HYGIENE  OF  THE  SCHOOL  CHILD 

9.  Children  with  much  outside  work  to  do. 

10.  Children  of  unusual  talent  in  some  line.  (Talent  crushed 
by  pressure  of  other  work.) 

11.  Children  of  general  mental  superiority.    (Held  back  by 
the  lock-step  of  the  school.) 

12.  Children    of    sub-normal    mental    endowment.      (Dis- 
heartened by  failure  and  repetition  of  work.) 

13.  Normal  children  whose  development  is  merely  belated. 

14.  Nervous  children,  including:  — 

(a)  those  with  tendency  to  chorea; 

(b)  those  who  stutter; 

(c)  those  who  suffer  disturbed  sleep; 

(d)  those  subject  to  headaches; 

(e)  those  who  are  abnormally  timid; 

(/)  those  who  are  oversensitive  to  praise  or  blame; 

(g)  those  of  neurasthenic  tendency; 

(K)  the  morbidly  precocious; 

(t)  children  who  are  over-imaginative  and  need  the 

corrective  furnished  by  contact  with  things  rather  than 

with  books. 

REFERENCES 

1.  Dr.  A.  Albu:  "Der  Antheil  der  Schule  an  den  Storungen  der 
Entwl.  u.  Ernahrung  der  Kinder."  Zt.f.  Pad.  Psych.,  1908,  pp. 
243-55. 

*2.  Giuseppe  Badaloni:  "Encore  du  travail  a  1'ecole  en  rapport  a 
la  fonction  de  la  respiration."  Inter.  Mag.  Sch.  Hyg.,  1910,  vol. 
vi,  pp.  153-65;  also  in  vol.  ii,  1906. 

3.  A.  Binet:  "La  consommation  du  pain  pendant  une  annee 
scolaire."  Z/' 'Annie  Psychologique,  vol.  iv,  p.  337  jf. 

4.  Borchmann:   Ueber  den  Einfluss  der  FereinkoUmien  avf  der 
Beschaffenheii  des  Blutes  des  Kindes.  Reviewed  in  Zt.f.  Schulges., 
1899,  pp.  320-23. 

5.  Victor  Bridon:  "Le  r61e  de  la  gaiete"  dans  1'education."   Inter. 
Mag.  Sch.  Hyg.,  vol.  I,  pp.  159-70. 

*6.  Dr.  Clement  Duke :  Needless   Injury   to  Children.    London, 

1899,  pp.  37. 
*7.  A.  Engelsperger  u.  O.  Ziegler:  "Beitr.  zur  Kentniss  der  physi- 

schen  u.  psychischen  Natur  des  sechsjahrigen  in  die  Schule 

eintretenden  Kindes."  7,t.f.  Exp.  Pad.,  vol.  I,  pp.  173-235,  and 

vol.  n,  pp.  49-95. 


SOME  EVIL  EFFECTS  OF  SCHOOL  LIFE    407 

*8.  Dr.  A.  Graziani:  "Einfluss  der  tibermassigen  Geistesarbeit  auf 
d.  Zahl,  Hamoglobingehalt  u.  auf  den  Widerstand  der  roten 
Blutkorperchen."  Zt.  f.  Schulges.,  1907,  pp.  337-53  (bibliog- 
raphy). 

*9.  Dr.  Helwig:  "Neuere  Untersuchungen  iiber  d.  Wirkung  des 
Untemchts  auf  den  kindlichen  Korper."  Inter.  Mag.  Sch.  Uyg., 
1911,  pp.  218-24. 

*10.  Hertel:  Overpressure  in  the  High  School*  of  Denmark.  London, 
1885,  pp.  44  +  148. 

11.  Ignatieff:  Der  Einfluss  der   Examina  auf  das  Korpergeuricht. 
Reviewed  in  Zt.  f.  Schulges.,  1898,  p.  244. 

12.  Mile.  loteyko:  "Le  surmenage  scolaire."    Rev.  Psych.,  1910, 
pp.  265-97. 

*1S.  G.  W.  Khlopine:  "Les  maladies  scolaire  parmi  les  eleves  des 
etablissements  d'enseignement  moyen  russes."  Inter.  Mag, 
Sch.  Hyg.,  1911,  pp.  280-91,  and  329-68. 

14.  N.  C.  Johnson:  "Habits  of  Work,  etc.,  of  High-School  Pupils 
in  Indiana."  Sch.  Rev.,  1899,  pp.  257-77. 

15.  Arthur  MacDonald :  "  Einfluss  der  Gehirnarbeit  auf  die  Atmung 
der  Schiller."  Zt.  f.  Schulges.,  1896,  p.  539. 

16.  Albert  Mathieu:  "La  question  du  surmenage  scolaire."  Inter. 
Mag.  Sch.  Hyg.,  vol.  iv,  1908,  pp.  419-31. 

*17.  Max  Oker-Blom:  "  Ueber  d.  Einfluss  verschiedenartiger  Schul- 

beschaftigung  auf  d.   Ventilation  der  oberen  Lungenteile." 

Inter.  Mag.  Sch.  Hyg.,  1911,  pp.  369-405. 
*18.  Dr.  E.  Quirsfeld:   "Zur   physichen   u.   geistigen   Entwl.   des 

Kindes  wahrend  der  ersten  Schuljahre."  Zt.f.  Schulges.,  1905, 

pp.  127-85. 
*19.  Dr.  Karl  Schmid-Monnard:  "Die  chronische  Kranklichkeit  in 

unseren  mittleren  u.  hoheren  Schulen."  Zt.  f.  Schulges.,  1897, 

pp.  593-615,  and  666-85. 
20.  Dr.  M.  Schuyten:  "Qu'est-ce-quele surmenage?"  Rev.  Psych., 

1908,  vol.  I,  pp.  143-57. 
*21.  Dr.  M.  Schuyten:   L education  de  la  femme.    1908,  pp.  458. 

(Chapter  n,  "Influences  psychique  immediates  de  1'ecole," 

pp.  177-88.   See  also  chapter  in,  "La  fatigue  intellectuelle.") 
22.  Dr.  M.  Schuyten:  "Rapport  sur  1'inattention;  ses  causes,  ses 

remedes."  Inter.  Mag.  Sch.  Hyg.,  1910,  pp.  503-09. 
*23.  Dr.  M.  Schuyten:  The  Nutrition  Coefficient  of  Antwerp  School 

Children.  Summary  by  the  author,  in  School  Hygiene,  1913,  pp. 

51-53. 

(For  further  statistics  on  the  prevalence  of  defects  see  other  chap- 
ters in  this  volume;  also  the  periodicals  and  all  standard  texts  on 
school  hygiene.) 


SUGGESTIONS 

FOR  A  TEACHER'S   PRIVATE  LIBRARY   ON 

THE  HYGIENE  OF  PHYSICAL  AND 

MENTAL  GROWTH 

*1.  JESSIE  H.  BANCROFT:  The  Posture  of  School  Children. 

1913,  pp.  327.  Macmillan  Co.,  N.Y. 
2.  LOUISE  STEVENS  BRYANT:  School  Feeding.     1913,  pp. 

345.     Lippincott  Co.,  Phil. 
*3.  W.  S.  CORNELL:  The  Health  and  Medical  Inspection  of 

School  Children.   1912,  pp.  614.   F.  A.  Davis  Co.,  Phil. 
*4.  F.  B.   DRESSLER  :  School   Hygiene.     1913,  pp.  369. 

Macmillan  Co.,  N.Y. 

5.  DAVID  FORSYTH  :  Children  in  Health  and  Disease.  1909, 
pp.  302.   P.  Blakiston's  Son  &  Co.,  Phil. 

6.  SIR  JOHN  E.  GORST:  The  Children  of  the  Nation.   1907, 
pp.  297.  Methuen  &  Co.,  London,  Eng. 

7.  LEONARD  G.  GUTHRIE  :  Functional  Nervous  Disorders  in 
Childhood.     1909,  pp.  300.     Oxford  University  Press, 
London,  Eng. 

*8.  E.  B.  HOAG:  The  Health  Index  of  Children.    1910,  pp. 

188.  Whitaker  &  Ray-Wi<rgin  Co.,  San  Francisco. 
*9.  E.  B.  HOAG  AND  LEWIS  M.  TERMAN:  Health  Work  in 

the  Schools.  Houghton  Mifflin  Co.,  Boston. 

10.  R.  TAIT  McKENZiE:  Exercise  in  Education  and  Medi- 
cine.   1910,  pp.  393.   W.  B.  Saunders  Co.,  Phil. 

11.  GEORGE  B.  MANGOLD:  Child  Problems.    1910,  pp.  352. 
Macmillan  Co.,  N.Y. 

*12.  ALBERT  MOLL:  The  Sexual  Life  of  the  Child.   1912,  pp. 

339.  Macmillan  Co.,  N.Y. 
*13.  NATHAN  OPPENHEIM:  The  Development  of  the  Child. 

1910,  pp.  296.     Macmillan  Co.,  N.Y. 
14.  G.  E.  PARTRIDGE:  The  Nervous  Life.     1911,  pp.  216. 

Sturgis  &  Walton  Co.,  N.Y. 


A  TEACHER'S  PRIVATE  LIBRARY         409 

*15.  WALTER  PTLE  :  Personal  Hygiene.  1910,  pp.  472.  W.  B. 

Saunders  Co.,  Phil. 
16.  STUABT  H.  ROWE:  The  Physical  Nature  of  the  Child. 

1899,  pp.  207.  Macmillan  Co.,  N.Y. 
*17.  E.  W.  SCRIPTURE:  Stuttering  and  Lisping.    1912,  pp. 

251.  Macmillan  Co.,  N.Y. 
18.  JOHN  SPAHGO:  The  Bitter  Cry  of  the  Children.  1909,  pp. 

337.  Macmillan  Co.,  N.Y. 
*19.  J.  M.  TYLER:  Growth  and  Education.    1907,  pp.  294. 

Hough  ton  Mifflin  Co.,  Boston.1 

1  The  books  in  the  above  list  which  are  most  likely  to  be  of  im- 
mediate help  to  the  teacher  are  marked  with  a  *. 


GLOSSARY 


aerate,  to  supply  with  air. 

alveolar  abscess,  "ulcerated 
tooth,"  or  "gum  boil." 

ambidextrous,  having  the  abil- 
ity to  use  both  hands  with 
equal  ease. 

ametropia,  any  kind  of  abnor- 
mal refraction  of  the  eye. 

anaemia,  deficiency  of  blood,  or 
of  red  corpuscles. 

anthropology,  the  science  of 
man. 

anthropometry,  a  branch  of  an- 
thropology which  is  con- 
cerned with  the  measurement 
of  the  human  body. 

aprosexia,  inability  to  give  at- 
tention. 

astigmatism,  a  refractive  error 
of  vision  due  to  unequal 
curvature  of  the  parts  of  the 
eye. 

asymmetry,  want  of  symmetry 
or  proportion. 

atrophy,  the  wasting  or  wither- 
ing of  an  organ  or  part  of  the 
body. 

bacteriology,  the  department 
of  zoology  which  deals  with 
bacteria. 

biennium,  a  period  of  two 
years. 

binocular  vision,  the  function- 
ing of  both  eyes  together  in 
vision. 


carious,  decayed. 

chorea,  "St.  Vitus's  Dance." 

choreiform,  resembling  cho- 
rea. 

cretinism,  a  form  of  feeble- 
mindedness due  to  defect  of 
the  thyroid  giand. 

dementia  praecox,  a  form  of  in- 
sanity which  usually  has  its 
onset  between  the  age  of  fif- 
teen and  forty  years. 

dendrites,  the  tree-like  branch- 
es of  nerve  fibers  extending 
from  the  nerve-cell. 

dental  caries,  decay  of  the 
teeth. 

dentine,  the  calcified  substance 
that  forms  the  main  part  of 
the  tooth. 

diathesis,  a  predisposition  to 
certain  forms  of  disease,  as 
"a  tubercular  diathesis." 

dynamogenic,  tending  to  pro- 
duce increased  nervous  ac- 
tivity. 

emmetropia,  the  condition  of 
the  eye  in  which  refraction 
is  perfect. 

eugenics,  the  science  of  im- 
proving the  human  race 
through  application  of  the 
laws  of  heredity. 

euthenics,  the  science  of  im- 
proving the  human  race 


GLOSSARY 


411 


through  the  control  of  en- 
vironment. 

habit-spasm,  an  aimless  and 
stereotyped  twitching  or 
contraction  of  one  or  more 
muscles  of  the  body. 

haematology,  that  branch  of 
medical  science  which  treats 
of  the  blood. 

haemoglobin,  that  part  of  the 
red  corpuscles  whose  func- 
tion is  to  carry  oxygen. 

Holmgren  test,  a  test  of  color 
vision  by  use  of  the  Holm- 
gren worsteds. 

hyperopia,  "far  sight." 

hypertrophied,  abnormally  en- 
larged. 

inhibition,  the  act  of  restrain- 
ing or  repressing,  as  to  check 
a  nervous  or  mental  process. 

kyphosis,  backward  curvature 
of  the  spine. 

laryngitis,  an   inflammation  of 

the  mucous  membrane  of  the 

larynx, 
lisping,  an  imperfect  utterance, 

like  the  substitution  of  th  for 

s  or  z. 
lordosis,  forward  curvature  of 

the  spine, 
lymphatic,    pertaining    to    the 

lymph. 

mastoid,  that  part  of  the  tem- 
poral bone  situated  directly 
behind  the  ear. 

medullation,  the  growth  of 
sheath  covering  the  nerve 


fibers  of  the  central  nervous 
system. 

"mental  complex,"  an  asso- 
ciated group  of  ideas  sub- 
merged below  the  level  of 
consciousness  and  producing 
pathological  mental  condi- 
tions. 

metabolism,  the  building-up 
and  tearing-down  processes 
of  living  material. 

migraine,  a  special  form  of 
headache. 

morbidity,  imperfect  state  of 
health. 

moron,  that  grade  of  feeble- 
mindedness just  below  nor- 
mality. 

myope,  a  near-sighted  person. 

myopia,  near  sight. 

neurasthenia,  a  chronic  state  of 
nervous  exhaustion. 

neuroglia,  the  supporting  tis- 
sue of  the  central  nervous 
system. 

neurosis,  a  nervous  disorder. 

neurotic,  predisposed  to  nerv- 
ous disorders. 

obsession,  a  fixed  idea;  an  idea 
that  persists  in  spite  of  ef- 
fort to  banish  it. 

oculist,  a  person  skilled  in 
treating  diseases  of  the  eye. 

optician,  one  who  makes  or 
deals  in  optical  instruments 
or  glasses. 

oral  hygiene,  the  hygiene  of  the 
mouth. 

orthodontia,  mechanical  treat- 
ment for  correcting  irregu- 
larity of  the  teeth. 


412 


GLOSS  AEY 


orthopsedia,  the  correction  or 

prevention  of  deformity  of 

the  body. 
orthophonia,  the  correction  or 

prevention  of  speech  defects. 
otitis  media,  acute  infection  of 

the  middle  ear. 
oxygenation,    supplying    with 

oxygen. 

pathogenic,  productive  of  dis- 
ease. 

pharyngitis,  inflammation  of 
the  mucous  membrane  of  the 
pharynx. 

phobia,  a  morbid  fear. 

phonation,  vocal  utterance. 

phylogenetic,  pertaining  to  the 
history  of  the  evolution  of 
the  species. 

prophylaxis,  preventive  treat- 
ment for  disease. 

psychiatry,  the  branch  of  medi- 
cine that  relates  to  mental 
disease. 

psychoanalysis,  a  method  of 
treating  functional  mental 
disorders. 

psychotherapeutics,  the  treat- 
ment of  mental  disorders  in 
general. 

radiograph,  an  X-ray  picture, 
rickets,  a  nutritional  disease  of 

childhood    affecting    chiefly 

the  bones. 


scoliosis,  lateral  curvature  of 
the  spine. 

septic,  productive  of  putrefac- 
tion through  the  action  of 
bacteria. 

sinistrality,  left-handedness. 

sinus,  a  slender  opening  or 
cavity. 

strabismus,  cross-eyedness. 

tartar,  a  yellowish  incrustation 
that  forms  on  the  teeth. 

therapeutics,  the  treatment  of 
disease. 

tic,  a  spasmodic  twitching  of 
muscles,  especially  of  the 
face. 

toxaemia,  a  poisoned  condition 
of  the  blood. 

toxin,  a  poisonous  compound 
of  animal,  bacterial,  or  vege- 
table origin. 

triennium,  a  three-year  pe- 
riod. 

unidextrous,  having  greater 
skill  in  one  hand  than  in  the 
other. 

vasomotor,  producing  contrac- 
tion or  dilatation  of  the 
walls  of  vessels;  as  the  blood 
vessels  of  the  skin. 

vertigo,  dizziness. 

vital  capacity,  the  ratio  of  lung 
capacity  to  weight. 


INDEX 


ADENOIDS,  136, 207  jf.;  causes  of, 
215;  effects  on  mental  and 
physical  development,  210  jf.; 
signs  of,  216. 

Alcohol  and  growth,  45. 

Allport,  Dr.  F.,  216 /. 

Appelt,  Dr.,  355. 

Arkle,  Dr.,  102. 

Astigmatism,  260  Jf. 

Ayres,  L.,  210. 

Badaloni,  Dr.,  397. 

Ballard,  P.  B.,  345  jf. 

Baths,  143. 

Bauer,  Dr.,  265  jf. 

Bell,  S.,  123. 

Bernhard,  Dr.,  365. 

Binet,  A.,  389. 

Biological  perspective,  13. 

Blood,  and  resistance  to  disease, 
48 ;  effects  of  school  work 
upon,  390 Jf.;  of  ill-nourished 
children,  112;  relation  to  res- 
piration, 151  jf. 

Boas,  F.,  22. 

Bobbitt,  J.  F.,  33. 

Book,  Dr.  W.  F.,  322. 

Books,  hygiene  of,  276  Jf . 

Borchmann,  Dr.,  395. 

Brown,  Dr.,  175. 

Bullock,  N.  K.,  212,  213  Jf. 

Burnham,  Dr.  W.,  15,  303  Jf. 

Butterworth,  Dr.,  264. 

Canavan,  Dr.,  73. 

Chorea,  and  rheumatism,  310. 

Circulatory  system,  growth  of, 

48. 

Claparede,  Dr.  E.,  363,  364. 
Clinics,  school  clinics,  376. 
Coffee,  effects  on  sleep,  376. 
Color-blindness,  272. 


Colyer,  Dr.,  180. 
Conradi,  E.,  336  jf. 
Conservation,  1  jf.,  6  Jf. 
Cornell,  Dr.,  212,  228,  268. 
Crampton,  C.  W.,  64  Jf. 
Crippled  children,  education  of, 

91  Jf. 

Cross-eye,  263  Jf. 
Crowley,  Dr.,  101. 

Deaf  children,  special  schools  for, 
239  Jf. 

Deafness,  prevention  of,  233. 

De  Busk,  B.  W.,  51. 

Defects,  percentages  of,  8;  statis- 
tics of,  383  Jf. 

Dental,  clinics,  192;  hygiene, 
167/. 

Desks,  81  Jf. 

Digestive  system,  growth  of,  50. 

Discipline,  and  nervousness,  324. 

Drafts,  160  Jf. 

Duke,  Dr.  C.,  363,  364,  367,  369. 

Ears,  221  Jf.;  causes  of  defects, 

228  Jf.;  discharging  ears,  227; 

signs  of  defects,  243. 
Engelsperger,  Dr.,  388. 
Environment  and  growth,  38. 
Epileptics,  316  Jf. 
Ernst,  Dr.,  183,  189. 
Eugenics,  34. 
Euthenics,  35. 
Examinations,  effects  of  school 

examinations,  391  jf. 
Eye,  245  Jf.;   eye-strain,  248  jf., 

264  Jf.;  squint,  2G3Jf. 

Fatigue,  during  school  year,  401 

/• 

Fears,  morbid  fears,  321  Jf. 
Feeble-mindedness,    15;   growth 


414 


INDEX 


of  feeble-minded  children,  28; 
relation  to  eugenics,  34. 

Feeding,  dietaries,  107;  inade- 
quate, 104  Jf. 

Fisher,  Irving,  4. 

Flat-foot,  87  jf. 

Food  habits,  123. 

Fraenkel,  Dr.,  133. 

Freud,  Dr.  S.,  320 /.,  355. 

Gibson,  Dr.,  175. 

Goddard,  H.  H.,  28,  371. 

Gould,  Dr.  G.  M.,  251. 

Grancher,  Dr.,  133. 

Graziana,  Dr.,  392  jf. 

Growth,  20  jf.;  and  scholarship, 
66;  circulatory  system,  48; 
digestive  system,  50;  disease, 
26;  disorders  of,  72  jf.;  effects 
of  school  upon,  44,  388  ff. ;  fac- 
tors influencing,  32;  glandular 
influence  on,  42;  influence  of 
alcohol  on,  45;  irregularity  of, 
59;  muscular  system,  52;  nerv- 
ous system,  57;  oscillations, 
25;  percentile,  24;  physiological 
development,  47;  prenatal  in- 
fluence on,  45;  relation  be- 
tween physical  and  mental,  27; 
respiratory  system,  51;  retard- 
ation, 29;  rhythms,  43 ;  sex  dif- 
ferences, 22  jf.,  63;  skeletal  sys- 
tem, 56 ;  social  influences,  36  jf . 

Gulick,  L.  T.,  141. 

Gutzmann,  Dr.  A.,  351. 

Hall,  G.  S.,  60. 

Hamburger,  Dr.,  132. 

Harrington,  Dr.,  104. 

Headaches,  282  ff. ;  and  eye- 
strain,  268;  causes  of,  283;  fre- 
quency of,  282;  prevention  of, 
287. 

Healy,  Dr.  R.,  317. 

Hearing,  causes  of  defects,  228 
ff.;  defects  of,  221  Jf.;  impor- 
tance for  mental  development, 
223  jf.;  methods  of  testing,  237; 
prevention  of  defects,  233;  sta- 
tistics of  defects,  221  jf. 


Height,  22. 
Helwig,  Dr.,  394  jf. 
Henneberg,  Dr.,  181. 
Heredity,  32;  and  dental  defects, 

190;    and   myopia,    259;    and 

speech  defects,  342;  and  visual 

defects,  259  jf. 
Hertel,  Dr.,  364,  382. 
High-school   pupils,   growth   of, 

65. 

Hill,  Leonard,  158. 
Hoag,  Dr.  E.  B.,  105,  206,  209, 

228,  252,  263,  267,  282,  376. 
Hoch,  Dr.,  308. 

Hocking,  Adeline,  362,  366,  368. 
Hodge,  C.  F.,  46. 
Hoesch-Ernst,  Lucy,  39. 
Hollingsworth,  H.  L.,  376. 
Holmes,  A.,  177. 
Hoist,  Dr.,  283. 
Home  study,  in  relation  to  sleep 

377. 

Hookworm  disease,  41. 
Hudson-Makuen,  Dr.,  335,  352. 
Huey,  Dr.  E.  B.,  277,  289,  344. 
Humidity,  155  jf. 
Hutchinson,  Dr.  W.,  284. 
Hygiene  instruction,  140. 
Hyperopia,  248,  253  jf. 

Ignatieff,  Dr.,  391. 
Insanity,  289. 

James,  W.,  326. 
Janet,  P.,  299. 
Jessen,  Dr.  E.,  167,  170. 
Johnson,  G.  E.,  171. 

Kafemann,  Dr.,  208  jf. 
Kelynack,  Dr.  T.  N.,  134. 
Kemsies,  Dr.,  84. 
Khlopine,  Dr.,  385  jf. 
Kirchner,  Dr.,  129  jf. 
Kobrak,  Dr.,  225  jf. 
Kraepelin,  Dr.  E.,  403. 
Kyphosis,  75  jf. 

Left-handedness,  55,  345. 
Liebmann,  Dr.,  354. 
Lindley,  E.  H.,  315. 


INDEX 


415 


Lobsien,  Dr.,  402. 
Lordosos,  77. 
Love,  Dr.,  240  ff. 
Lunches,  school  lunches,  105. 

Mackenzie,  W.  T.,  39. 

MacMillan,  D.  P.  (and  Bodine), 
100. 

Magelssen,  283. 

Mailing-Hanson,  43,  68. 

Malnutrition,  98  ff.  (see  also  Nu- 
trition); amount  of,  99;  and 
dental  defects,  188  Jf . ;  causes 
of,  104  jf.;  evils  of,  98;  symp- 
toms of ,  108  ff. 

Manaceine,  Dr.  M.,  364. 

Mastication,  174;  and  dental  de- 
fects, 174. 

Maturity,  anatomical,  14;  physi- 
ological, 14. 

McCallie,  Dr.,  271. 

Measles,  48. 

Medullation,  of  nerve  fibers, 
57  jf. 

Mental  hygiene,  289  Jf .,  299  Jf., 
318  ff. 

Metabolism,  50,  108. 

Meyer,  Dr.  A.,  307  jf. 

Michael,  Dr.,  188. 

Migraine,  286. 

Morbidity,  14. 

Mortality,  14. 

Mouth,  breathing,  201;  hygiene, 
191. 

Muscular  system,  growth  of, 
52 

Myopia,  249,  255  jf. 

Nasal  hemorrhage,  386. 

Nervousness,  and  chorea,  310 jf.; 
and  headaches,  285;  and  moral 
disorders,  317;  and  shock,  238; 
and  stuttering,  355;  and  sui- 
cides, 329  ff.;  dementia  prae- 
cox,  306;  description  of  a  nerv- 
ous child,  289  ff.;  education 
of  nervous  children,  318  jf.; 
hysteria,  302;  in  relation  to 
defective  teeth,  177;  morbid 
fears,  321  jf.;  preventive  men- 


tal hygiene,  289  Jf.,  299  jf.,  318 
jf.;  psychasthenia,  299  jf.; 
school  epidemics,  303  jf.;  sug- 
gestions for  observation,  297 
jf.;  symptoms,  289  jf.;  tics  and 
habit-spasms,  313  jf. 

Nervous  system,  growth  of,  57. 

Netschajeff,  Dr.,  370. 

Newmayer,  Dr.,  224. 

Night  terrors,  377. 

Nose  and  throat,  as  related  to 
hearing,  299. 

Nose,  hygiene  of,  197  jf.;  relation 
to  health,  197  jf. 

Nutrition,  39  jf.  (see  also  Malnu- 
trition) ;  effects  of  school  upon, 
390  jf.;  effects  on  teeth,  188; 
physiological  factors,  123. 

Oker-Blom,  Dr.  M.,  397. 

Oltuszewski,  341. 

Open-air  schools,  165;  effects  of 

nutrition,  120. 
Oppenheimer,  111. 
Oral  hygiene,  167  jf. 
Orthodontia,  193. 
Osier,  Dr.  Wm.,  167. 
Over-pressure,  381  jf. 

Paul,  Dr.,  158. 

Pearson,  K.,  34. 

Pedley,  Dr.,  169,  176,  183  jf. 

Phillips,  Dr.,  130. 

Physical  education,  17. 

"Physiological  age,"  61  jf. 

Physiological  development,  47. 

Pigeon-breast,  86. 

Playgrounds,  143. 

Pollak,  Dr.,  135. 

Porter,  W.  T.,  97  ff. 

Posture,  hygiene  of,  72  jf . 

Precocity,  29. 

Preventable  diseases,  cost  of,  8  jf. 

Psychic  epilepsy,  316. 

Quirsfeld,  Dr.,  389. 

Ravenhill,  Alice,  367,  374. 
Respiration,   150  jf.;   effects  of 
school  upon,  397  Jf. 


416 


INDEX 


Respiratory  system,  growth  of, 
51. 

Retardation,  and  defective  hear- 
ing, 223  jf.;  and  malnutrition, 
100;  and  sleep,  369  Jf.;  effects 
of  adenoids  on,  210  ;  effects  of 
defective  teeth  on,  179. 

Rheumatism,  and  chorea,  310; 
and  tonsils,  204. 

Richards,  Mrs.  E.,  119. 

Rickets,  79  jf. 

Right-handedness,  55,  345. 

Rose,  Dr.,  189. 

Rotch,  T.  M.,  62  jf.,  27. 

Roth,  Dr.,  75. 

Rothfeld,  Dr.,  86. 

Rouma,  G.,  339,  347. 

Round  shoulders,  75. 

Rubner,  Max,  120. 

Schmid-Monnard,  Dr.,  383  Jf., 
388. 

School,  and  fatigue,  401  jf.;  as 
a  cause  of  morbidity,  383  Jf.; 
clinics,  144;  effects  on  respira- 
tion, 397;  effects  upon  growth, 
388  jf.;  effects  upon  nutrition, 
390  jf.;  evils  produced  by,  381 
jf.;  physician,  9;  psychopatho- 
logical  effects,  398  jf. 

Schuyten,  Dr.,  Ill,  389 jf.,  398  jf. 

Scoliosis,  77. 

Scripture,  E.  W.,  335,  351,  356. 

Shock,  328. 

Sidis,  Dr.  B.,  326. 

Skeletal  system,  growth  of,  56. 

Sleep,  362  jf.;  amount  needed,  363 
Jf. ;  amount  secured,  364  jf. ; 
and  nervousness,  376 ;  condi- 
tions of,  372  jf. ;  relation  to 
intelligence,  369  jf. ;  suggestions 
for  a  sleep  survey,  378. 

Special  schools,  for  children  with 
defective  vision,  275;  for  deaf 
children,  239  jf.;  for  nervous 
children,  330 ;  for  stuttering 
children,  347  Jf. ;  orthopedic 
classes,  85. 

Speech  defects,  335  jf.;  frequency 
of,  336  jf.;  lisping,  338  jf.;  stut- 


tering, 335,  340 Jf.;  suggestions 

for  observing,  360. 
Spinal  curvature,  73  jf.;  causes 

of,  79  Jf.;  injuries  produced  by, 

78;  treatment  of,  84  jf. 
Squint,  263  jf. 
Squire,  Dr.,  123. 
Still,  Dr.,  261. 
Stockard,  C.  P.,  45. 
Stuttering,  335  jf.,  340  Jf.;  causes 

of,  341;  prevention  of,  357  jf.; 

treatment  of,  347  jf.,  351. 
Suicides,  of  children,  329  jf. 

Teeth,  167  jf.;  causes  of  decay  of, 
183  jf.;  cleanliness  of,  186; 
defective  teeth  and  growth, 
180;  defective  teeth  and  men- 
tal development,  178;  import- 
ance of  temporary  set,  188 ; 
injuries  produced  by  defective 
teeth,  173;  orthodontia,  193; 
prevention  of  decay,  191;  sta- 
tistics of  defects,  169  jf.;  ulcer- 
ated teeth,  155  jf. 

Temperature,  155  jf. 

Terman,  L.  M.,  40,  137,  144,  330, 
368,  396. 

Throat,  hygiene  of,  197  jf. 

Tonsils,  202  jf.;  and  rheumatism, 
204;  diseased  tonsils,  202  Jf. 

Tonzig,  Dr.,  117. 

Triplett,  N.,  403. 

Tuberculosis,  127  jf.;  in  children, 
129;  of  the  bone,  136;  pre- 
vention of,  137  jf.;  ravages  of, 
127  jf. 

Underwood,  Dr.,  189. 

Vacation  colonies,  140. 

Ventilation,  148  jf.;  and  air  cur- 
rents, 155;  and  humidity,  155 
jf.;  and  temperature,  155;  of 
bedrooms,  373. 

Vision,  245  jf.;  directions  for  test- 
ing, 269  jf . ;  frequency  of  de- 
fects of,  251  jf.;  mechanism  of, 
247  jf. 

Vital  capacity,  51. 


INDEX 


417 


Vocational  guidance,  140,  278. 
Voice,  hygiene  of,  335  jf . 
Von  Pirquet,  Dr.,  132. 

Wallace,  Dr.  S.,  186. 
Wallin,  J.  E.,  179. 
Ward,  Mrs.  H.,  91. 
Weight.  23. 


Weygandt,  Dr.,  370. 
Williams,  Dr.  T.,  301. 
Wimmenauer,  Dr.,  102,  111. 
Wingerath,  Dr.,  257. 
Work,  wholesome  effects  of,  327 

Yearsley,  Dr.,  209,  212,  239. 
Young,  Dr..  136. 


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